Work Modifications

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Talking Work: A guide for Doctors discussing work and work modifications with patients.

Talking Work Checklist

This ‘Talking Work’ checklist can be used by Doctors to have work-related conversations and to consider adjustments as part of their routine consultations. The Talking Work guide provides detailed guidance on each of these specific activities.

  1. Confirm patient’s job title and role is correctly recorded at each consultation.
  2. If not, obtain and record new job title and consequent change in duties.
  3. Does the patient need a fit note? If yes, proceed to Step 4, else no further actions on this checklist needed.
  4. Are there any red flags likely to affect their ability to do their job duties? If yes, sign them off with scheduled follow up to reconsider when the condition may have changed.
  5. If no red flags, ask the patient how they see their symptoms, and what adjustments they think might make a difference, so that they could go back to or continue in work?
  6. Consider adjustments options provided in section 4 of the ‘Talking Work’ guide.
  7. If the patient has some limitations but may still be able to continue work, provide a recommendation for a workplace meeting to discuss adjustments and modified duties using ‘may be fit’ selection.
  8. Encourage communication between patient, employer and other relevant stakeholders.

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Guidance Summary

It is imperative that doctors highlight the drawbacks of long-term sickness absence and consider all options possible for the patient to be able to sustain or return to work before signing them off. This guide provides suggested questions to encourage work-related discussions, responses to queries and recommended resources to which employers and patients can be referred for further detailed information or assistance.

At a matter of routine, patient’s work and job title should be confirmed at each consultation. If they have changed roles, doctors can check how it has impacted the patient and update the records. This will ensure that work related conversations are part of routine healthcare consultations (Guide Step 1).

Doctors should avoid using language which may make the patients think that all work-related activities may be harmful and they should not continue to work unless there is evidence that the findings may be the cause of patient’s presentation (Guide Step 2).

Having an illness or injury doesn’t necessarily mean that the patient is unable to perform their job or carry on their daily activities. It is important to understand the impact any condition is having on the patient’s ability to work. This can be done through specific questions about their role and limitations due to health condition (Guide Step 3).

Work modifications may include adjustments to work arrangements, work premises or job and workload – often temporary to facilitate staying at or returning to work, with the aim being to return to usual job. Most of the adjustments can be implemented easily and at little or no additional cost to the employers (Guide Step 4).

If the patient has some limitations, but may still be able to continue work, encourage them to have a conversation with their line manager to discuss work modifications and changes in work arrangements that can be made to allow them to continue working. (Guide Step 5).

For more complex adjustments or equipment / premises modification needs, patient and employers require specialist occupational health input, a specialist organisation related to that condition or may be able to request a workplace assessment from Access to Work (Guide Step 6).

Doctors can help stimulate dialogue about health in the workplace through suggesting return to work meetings, referral to Access to Work scheme or to Occupational Health (Guide Step 7).

This information can be highlighted on the fit note using the ‘may be fit for work’ option. In the fit note, a recommendation for a workplace meeting to discuss adjustments and modified duties may be all that is required for the patient to have such discussion with his line manager and agree on a period of graduated return to work (Guide Step 8).

This guide is accompanied by case studies highlighting how doctors can use fit notes to sustain or enable a return to work for patients with a variety of health conditions.

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Why ‘Talking Work’ is our business?

Appropriate work promotes physical and mental health, enhances sense of purpose, self-confidence, self-worth, independence and fulfilment. Where appropriate, remaining in or returning to “good” work should be a critical outcome measure for success in the treatment and support of working age people (Department of Health, 2017).

The long-term consequences of advising or agreeing that a patient should stay off work may be greater than those of the original health problem. The danger is the patient drifting into long-term sickness. Prolonged sickness absence, long-term incapacity and ill-health retirement can have highly damaging effects on the lives of patients and their families (Black and Frost 2011).

As a professional responsible for issuing fit notes, doctors are responsible for supporting and, where appropriate, supportively challenging the patient’s informed decision as to whether they can stay in or return to work. Employers and employees generally tend to follow the guidance of the doctor when someone should continue to sustain or return to work (McDonald et al 2012). Therefore, it is imperative that doctors consider all options possible for the patient to be able to sustain or return to work before signing them off and highlight the drawbacks of long-term sickness absence.

Having a diagnosis does not immediately constitute being unable to work. Many people with long-term health conditions and disabilities continue to work and others would be able to work if they were offered the right support and environment along with adjusting the job to their requirements. Equally people who have suffered acute injuries/ illness may be able to sustain their previous work if reasonable adjustments are made to their roles. Though as clinicians, we recognise that despite our best efforts, some people may not be able to work due to illness/ disability (Black and Frost 2011).

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How can I best help my patients with work issues given that I am not trained in occupational health?

Doctors are not expected to have specialist knowledge of workplaces or occupational health. However, understanding the impact a patient’s condition may have on their functional job roles is the key to providing a useful opinion on the patients’ ability to return to work. doctors are not required to comment on specific job requirements, but rather the physical/ mental/ other restrictions the patient should adhere to e.g. limits on bending, lifting, reduced hours etc. Public Health England have also developed an online training programme for a wide range of HCPs, to support patients return or remain in work through work discussions during clinical interactions. It can be accessed through this link.

‘Talking work’ with patients doesn’t have to be time consuming. It needn’t take away the focus of your routine consultation which is about supporting and managing patient to manage their health condition. However, work is a key aspect of most people’s lives. This guide helps you provide tools to start work related conversations. We provide suggested questions, responses to queries and recommended resources to which employers and patients can be referred for further detailed information or assistance.

  1. Understand your patient’s work
  2. Use realistic positive language when discussing a diagnosis
  3. Understand the limitations and opportunities to patient’s work due to their condition
  4. Consider adjustments that may allow patient to continue working or return to work
  5. Encourage discussion with line manager
  6. Encourage patients to seek Access to Work
  7. Encourage communication between stakeholders
  8. Supporting patient and employer with relevant information on fit note
  9. Duty for employers to make reasonable adjustments for disabled staff

1. Understand your patient’s work

As a part of registration at a GP practice, work-related information is usually obtained. This can include the job title and description of duties of the role.

If this information is available within the patient record, at each clinical consultation, doctors can ask the patient about their role and whether they are continuing in the same role.

“I see from the records, Mr Smith, you work as a roofer, is that still the case?”

If they continue to work in the same role, this provides the affirmation and the opportunity for the patient to highlight any potential work-related issues which may be contributing to their health. It is important for doctors to understand these contributory factors to better manage the health condition.

If they have changed roles, it gives the patient an opportunity to highlight the change. In such cases, doctors can ask about the change and how it has impacted the patient.

“Oh, so now you work as a Site Supervisor. Has that changed your duties considerably?”

The changed role can be updated on the records.

This routine conversation should not be time consuming. It gives the doctor an understanding of the patient’s work role and an opportunity for the patients to highlight any work-related issues which can provide indications for potential impact on health and recovery. This process also ensures that work-related conversations become a routine aspect of the clinical consultations with the doctor.

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2. Use realistic positive language when discussing a diagnosis

The words used by doctors for describing the condition or diagnosis for the patient have a powerful impact on how the condition, its prognosis and impact on their daily life is perceived. There is a significant body of evidence to suggest that labelling an individual with a medical or mental condition using words that may unintentionally alarm may lead to inappropriate expectations, mistaken beliefs or fears. Diagnosis can be distressing when it is perceived as undermining individual identity, causing feelings of shame or loss when individuals feel like they were just a diagnosis, a “freak”, or worthless. On the contrary, if a diagnosis is offered carefully, with time for discussion, clear information and hope, it is more likely to be experienced positively (Perkins et al. 2018).

Doctors should avoid using catastrophic and alarming words which may make the patients think that all work-related activities may be harmful and they should not continue to work unless there is evidence that the findings may be the actual cause of patient’s presentation.

Neutral and supportive words (see below) indicating the appropriate management strategy may be more helpful to allow the patients to continue their daily routine and maintain their functional ability.

Neutral description – Do say “Catastrophic” terms – Do not say
You may have a degenerative joint disease. You have a crumbling spine
Explain natural age-related changes and how staying active or exercising, as appropriate, can help reduce the impact of age-related changes. Your spinal space is narrowed
Your joints are worn

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3. Understand the limitations and opportunities to patient’s work due to their condition

Having an illness or injury doesn’t necessarily mean that the patient would be unable to perform their job or carry on their daily activities. It is important to understand the impact any condition is having on the patient’s ability to work. Ask questions such as:

“How is (health condition) affecting you?”

“How does this impact on your work role?”

“Which tasks you think you can manage even with (health condition)?”

“What job tasks are difficult because of this (health condition)?”

“Are there any safety critical aspects which may be affected by (health condition)?”

Working alongside the patient classify their work activities in three categories:

  1. Activities/ aspects of the role they consider may aggravate their condition
  2. Activities/ aspects of the role they consider can be safely completed
  3. Activities/ aspects of the role they are unsure about whether they may be able to complete

This allows the patients to highlight specific areas of concern while also reflecting on other aspects of their work role which they may be able to continue despite the presenting condition and consequent limitations. The focus of conversations should be on ability and what activities they may be able to continue undertaking safely and without detriment to their health.

If there are certain activities which the patient considers that can be safely completed, then within the fit note, consider using ‘may be fit for work’ and highlight these activities and encourage the employer to consider a workplace assessment to confirm suitability of the patient to continue working either in the same or modified role subject to the restrictions identified.

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4. Consider adjustments that may allow patient to continue working or return to work

Adjustments may include amendments to work arrangements, work premises or job and workload often temporary to facilitate staying at or returning to work, with the aim being to return to usual job. Most of the adjustments can be implemented easily and at little or no additional cost to the employers. Understanding the work role and limitations imposed by the presenting condition are key to identifying appropriate adjustments. Most times the patients may be able to suggest possible adjustments to allow them to continue or return to work themselves, however sometimes they may still be learning to cope with the condition and therefore do not understand what adaptations may be reasonably practicable for their employers to undertake to support them to stay at work.

For more complex adjustments or equipment / premises modification needs, patient and employers may require specialist occupational health input, or may be able to request a workplace assessment from Access to Work (See Step 7 below). Some of the aspects for the doctor to consider when discussing adjustments with patients are:

Altered work arrangements
  1. Working from home (e.g. a patient who has suffered a lower limb fracture but is a sedentary office worker may be able to complete their duties while working from home)
  2. Moving the patient to a worksite closer to home or on to ground floor or to a quieter space.
  3. Reducing or changing work hours (to facilitate graduated return to work, enhance endurance and readjust to workload and routine e.g. someone who has not worked for several months may struggle to return to full time hours but can gradually build up to it through starting work half days or alternate days for a few weeks, can include starting or finishing earlier or later, but also may be a permanent adjustment)
  4. Longer or more frequent breaks
  5. Time off to attend medical or rehabilitation appointments (e.g. physiotherapy or counselling appointments)
  6. Flexible working arrangements

 

Additional Support Arrangements:
  1. Provide additional supportive personnel (e.g. a driver who may have no limitations in driving but is unable to bend and lift may continue to work if additional support may be provided in lifting and loading where necessary).
  2. Providing support for travel to and from work (e.g. if the patient is unable to drive or use public transport)
  3. Provide a closer parking space
  4. Redeployment to alternative role (either temporary or permanent)
  5. Providing additional training, supervision, instructions, mentoring or support
  6. Extra help with managing and negotiating workload
  7. Debriefing sessions after difficult work tasks
  8. Use of mentorship or buddy support systems
  9. Provide regular opportunities to discuss, review and reflect on people’s positive achievements – this can help people to build up positive self-esteem and develop skills to better manage their triggers for poor mental health.

 

Workplace modifications or equipment:
  1. Moving furniture, widening a doorway or providing a ramp so that a person using a wheelchair or other mobility aid can get around comfortably and safely;
  2. Move a person with hearing impairment to an area with less background noise;
  3. Changing seat to an area with natural light for someone with seasonal depression
  4. Provide special equipment (such as an adapted keyboard for someone with arthritis, digital recorder for someone who finds it difficult to take written notes or a large screen for a visually impaired workers), an adapted telephone for someone with a hearing impairment, or other modified equipment for disabled workers (such as longer handles on a machine).
  5. Provide BSL interpreters or lip speakers for a person who is deaf or hard of hearing, or screen readers which will read out documents for someone with low vision or learning disability.

 

These adjustments are provided as a guide to highlight the range of options possible and is not exhaustive. It is anticipated that doctors will utilise this guide to make personalised suggestions within the fit note and then the patient and employer can agree on the recommendations or seek specialist input from an occupational health provider and/or Access to Work.

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5. Encourage discussion with line manager

If the patient has some limitations, but may still be able to continue work, ask the patient if they have had a discussion with their line manager about the condition and how it is impacting their job tasks. If they do not have a line manager, then consider who could support their return to work. Patients can also consider if their employer has an employee assistance program (EAP) which would assist in their condition.

“Have you discussed this with your line manager?”

“Could you avoid doing these two (limited) tasks and still carry on working?”

“Can you discuss with your line manager if they can make any accommodations to reduce these problems?”

The patient should ask to talk to their manager/employer about the matter. A meeting can provide them with an opportunity to explain the situation more clearly and suggest possible
adjustments. It will help the employer understand how best they can support and help the patient. It may also be helpful for the line manager to include other relevant people such as safety reps or HR in these discussions.

In the fit note, a recommendation for a workplace meeting to discuss adjustments and modified duties may be all that is required for the patient to have such discussion with his line manager and agree on a period of graduated return to work.

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6. Encourage patients to seek Access to Work

As discussed above, most adjustments may be simple and inexpensive and therefore can be agreed between the patient and their line manager. However, employers may wish to request a workplace assessment for more complex adjustments through the Access to Work (AtW) scheme. Access to Work is a Government service where an application is made by the employee initially by telephone or online.

Access to Work may provide a grant to cover the cost of:
  • adaptations to the equipment
  • special equipment or software
  • British Sign Language interpreters and video relay service support, lip speakers or note takers
  • adaptations to patient’s vehicle so they can get to work
  • taxi fares to work or a support worker if they cannot use public transport
  • a support worker or job coach to help them in their workplace
  • a support service if they have a mental health condition
  • disability awareness training for work colleagues

 

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7. Encourage communication between stakeholders

Doctors can help stimulate dialogue at the workplace through suggesting return to work meetings, referral to Access to Work scheme and/or to an occupational health provider. However, it is important that, with appropriate consent, information regarding work and health is shared between interested parties to improve the care and support provided to someone at risk of falling out of work, or on sickness absence. This will contribute to the development of a better and integrated health system for patients.

GP practices may set up a channel of communication for employers to facilitate discussion of the patient’s return to work should the employer wish to do so, and with the employee’s consent. However, patient confidentiality would need to be maintained. This may be in the form of a dedicated email address where there is no patient identifiable information in any mailings from the practice.

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8. Supporting patient and employer with relevant information on fit note

It is important to recognise that most patients facing long-term absence would prefer to return to work and similarly most of unemployed would prefer to be in work. Doctors can play a crucial role in facilitating these discussions by the above steps: understanding the patient’s work, how their condition is impacting them and encouraging discussion of alternative work options with the line manager. It may also be relevant to highlight the timeframe for which the adjustments may be required. This information can be highlighted on the fit note using the ‘may be fit for work’ option. As the guidance for completing the fit note states this gives maximum flexibility to the patient and their employer to discuss ways to accommodate your patient’s condition.

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9. Duty for employers to make reasonable adjustments for disabled staff

Where someone meets the definition of a disabled person in the Equality Act 2010[1]their employer is required by law to make reasonable adjustments to any elements of the job that place that disabled person at a substantial disadvantage compared to non-disabled people.

 

Reasonable adjustments are different to “workplace modifications”, which might voluntarily be put into place to help somebody back into work, for example after suffering an acute injury or an illness that is likely to last less than 12 months. Because employees in these examples would not meet the definition of a disabled person under the Equality Act, employers are not obliged to provide workplace modifications. However, if the employee is a disabled person, then reasonable adjustments are required by law and the failure to provide one could be found to be disability discrimination.

 

The duty to make reasonable adjustments arises in three situations:

  • where a provision, criterion or practice applied by or on behalf of the employer,
  • where a physical feature of premises occupied by an employer, or
  • where the lack of an auxiliary aid,

places a disabled person at a substantial disadvantage compared with people who are not disabled. An employer has to take such steps as it is reasonable to take in all the circumstances to avoid that disadvantage – in other words the employer has to make a ‘reasonable adjustment’.

 

However, employers are only required to make adjustments that are reasonable. Factors such as the cost and practicability of making an adjustment and the resources available to the employer may be relevant in deciding what is reasonable.  The lawis clear that if there isn’t an adjustment that can reasonably be made to avoid a disadvantage, then an employer can lawfully decline the request.

 

Further information for employers on the duty to make reasonable adjustments for disabled employees can be downloaded from the Gov.uk website through the following link:  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/138118/Equality_Act_2010_-_Duty_on_employers_to_make_reasonable_adjustments_for….pdf

[1]Further guidance on this can be found here: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/570382/Equality_Act_2010-disability_definition.pdf

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Case Studies

  1. Cardiorespiratory
  2. Musculoskeletal
  3. Cancer
  4. Injury at work
  5. Mental Health

1. Cardiorespiratory

Dr Spike assessed Fred, a 55 year-old assembly line worker, due to his ongoing complaints of shortness of breath on exertion, fatigue and respiratory distress. Fred is a long-term smoker and is likely that in the long term may not be able to undertake the core duties of his role as an assembly line worker which include lifting 25kg loads, frequently, bending, and stooping, ability to stand up to 8 hours. Fred has taken several days off on multiple occasions within the last one year.

Fred presented with reduced stamina and dexterity as well as being stressed about the impact the condition will have on his ability to work and support his family.

Dr Spike gave a fit note to Fred which stated that he may be fit to work with adjustments and described his condition and the limitations it imposes. In the comments, he also suggested a work review between Fred and his line manager to consider reasonable adjustments which may be made to allow Fred to continue working. Fred felt much more confident following this discussion and was able to discuss his issues in detail with his line manager Sam.

Example fit note:
Fred has breathing difficulties, is breathless on exertion, and has fatigue as a result. He may continue to work with some adjustments to his role. Consider reduced lifting and standing roles. Suggest workplace review.

Sam suggested a redeployment of his role to more sedentary role of a different assembly line where Fred was not required to undertake heavy lifting and would be seated for the duration of his shift, thus reducing chances of exertion induced shortness of breath. Dr Spike had already referred Fred to a smoking cessation service, for which he was able to use his flexible working time once a week. Fred was able to continue working in his new role and did not have any further absences from work.

Summary:
Through an understanding of the role and encouraging conversation with the employer through the fit note, the GP was able to support Fred in sustaining his work role. The adjustments provided by Sam did not cost any significant money but made Fred feel supported and valued.

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2. Musculoskeletal

Emma is a 45 years old carer in a mental health facility where she is responsible for provision of care and support for children/adolescents with learning disabilities such as autism. Her role involves physical work and manual handling. She also has to be involved in restraining service users during episodes of acute distress/anger outbursts. Consequently, she may need to hold awkward positions for sustained periods. She also has to work night shifts when there are reduced staff levels.

As a result of a previous incident, Emma has suffered from low back pain for several years. She again suffered an aggravation and has taken time off work as she is unable to handle the manual duties of her role. She attended her GP surgery to get a fit note after being off work for 3 days. She insisted that she will not be able to return to work because of her high levels of pain. Her GP prescribed her co-codamol and signed her off work for 1 week. At follow up, her pain levels had subsided somewhat, but she wanted to some more time off as she felt that she would struggle to bend, lift and carry, the tasks that she does have to undertake often in her duties as a carer.

Her GP asked her whether she could be doing alternate duties which don’t involve these activities. Her GP asked her if she would like to check with her manager if she could be doing something which doesn’t involve manual handling? In the fit note, the GP suggested ‘may be fit for work’ and highlighted the limitations Emma was experiencing.

Example fit note:
Emma has low back pain worsened with bending, lifting and carrying. May be able to return to work in altered duties which do not involve these activities. Consider review with manager or occupational health.

Emma had a review meeting with her manager who suggested that Emma works on the office desk answering phone calls during the day. This would mean that she would not be involved in any manual handling activities. She was advised not to undertake night shifts when there is less staff and even desk staff may need to get involved in restraining activities. Emma and her manager agreed to review these arrangements in 4 weeks.

Summary:
Alternate duties which do not involve activities which exacerbate the condition may be considered without any detriment to the patient. GPs/HCPs do not necessarily need to know all the alternate arrangements available as that will depend on the workplace and their requirements. With GPs support and encouragement, Emma was able to continue working albeit in a different role until she felt ready to be able to return to her substantive role.

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3. Cancer

Lyn is a 51 year-old shop floor assistant with a large retailer. Her work requires her to be on her feet for long periods of time and to sometimes lift heavy items. Lyn was diagnosed with breast cancer and she underwent a course of chemotherapy. She also needed a lumpectomy subsequently. Now that her treatment has completed, she is waiting to find out if she will need more treatment.

When she visits her GP, Dr Verma, she tells her that she is beginning to feel a bit better and is thinking about returning to work. But she is concerned about fatigue, because she usually works full-time and whether she will be able to complete her full shift as she has to stand for long periods of time without any option to sit down. She only gets a 30 minute break.

Dr Verma asks her whether she could be doing alternate duties which don’t involve long periods of standing or whether she may be able to do fewer and smaller shifts with more breaks. Lyn said that she would be happy to try it. In the fit note, Dr Verma suggests “may be fit for work’ and highlights the limitations Lyn is experiencing.

Example fit note:
Lyn has fatigue and is unable to undertake heavy lifting. She may be able to continue working with some adjustments to hours, more rest breaks and no lifting responsibilities. Consider review with manager or occupational health.

Lyn shares the fit note with her line manager and they’re able to agree that she works half days and has more rest breaks to help her manage her fatigue. She can also be exempt from heavy lifting duties. They agree to review the situation as and when Lyn knows more about the success of her treatment so that they can understand what, if any, additional adjustments might be necessary.

Summary:
Despite some limitations, with support and encouragement from her GP and line manager, Lyn was able to return to work doing her routine duties with some adjustments. Doctors don’t necessarily need to be able to identify alternative arrangements. If there are no red flags and the patient can return to work without detriment, then highlighting the limitations (e.g. fatigue and lifting) in the fit note with encouragement of a graduated return to work can help patients get back to work.  A diagnosis of cancer requires consideration of reasonable adjustment under the Equality At 2010.

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4. Injury at work

Mr Smith, a claims handler, presents to the GP surgery for a further fit note. He experienced a lower limb fracture when he slipped and fell at his workplace. His fracture was managed conservatively in a plaster cast at the A & E. On discussion, Dr Sharma understands that Mr Smith works in a sedentary back office role which involves answering telephone calls and working on the computer for administrative duties managing insurance claims. Whilst the nature of the injury has no direct impact on the patient being able to complete the core duties of his role (which involve sitting for long duration), he is now unable to drive which means that getting to work is difficult. Mr Smith doesn’t have any family members or friends who can drop him off to work. Mr Smith also considers that he would find sitting with his leg in dependent position difficult and it may increase the swelling in his legs.

Rather than signing him off sick, Dr Sharma discussed with Mr Smith whether there may be opportunity for flexible working from home or the employer may be able to provide a car share/ taxi service to manage the transportation issue. Mr Smith wasn’t sure if that would be the case.

Example fit note:
Mr Smith has a fracture of the left lower leg (tibia). Managed in plaster cast. Can’t drive until cast removal. As a claims handler, may be able to continue working in sitting role with altered work arrangements or support in transportation. Discuss with line manager.

Dr Sharma used the fit note to sign ‘may be fit for work’ and highlights the issues discussed and recommends Mr Smith’s line manager to consider altered work arrangements. Having this discussion with his GP made Mr Smith feel that he may be able to continue working rather than take another 4 weeks off work for which he is only being paid statutory sick pay.

Mr Smith met with his line manager who was very supportive considering adjustments and help him return to work. His line manager allowed Mr Smith to work from home for 2 months. He continued to work in his pre-injury role except for answering phone calls which were diverted to his team members. He was able to join the meetings through video conferencing. Once his fracture was healed and he regained his mobility, he was able to return to working in the office.

When Mr Smith started to work in the office, he noticed that his feet were swelling up as he sat in the chair for long periods. When he discussed with this with Dr Sharma at a follow up visit, he advised Mr Smith to elevate the leg at regular intervals throughout the day to disperse swelling.  Mr Smith discussed this with his line manager who allowed him extra breaks every 2-3 hours so he can use the staff room couch to lie down for 10-15 minutes to elevate his leg. He was also given a foot stool to use whilst he was working at his desk to elevate his leg intermittently.

Mr Smith continued to work in his role as a claims handler without taking any time off. Over a period, he noticed that his feet were not swelling anymore and he was able to discard the use of the foot stool and didn’t require the extra breaks.

Summary:
The above example highlights how a brief discussion about work role, the physical demands of the role and the impact of the condition on patient can be used to determine suitability to continue working as well as identify adjustments which the employer/patient can consider in their discussions.

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5. Mental Health

Sateesh is a 38 year old accountant working for a large multinational corporate. He has a past history of anxiety and depression brought on due to family issues. He suffered an acute exacerbation of anxiety due to work-related stress and has been off from work for 6 weeks. He presents to his GP, DrAzzopardi for a review and requests a further fit note. He states that whilst he is feeling better, he is unsure that he will be able to return to work and cope with the stress of the work. It is near financial year end and there will be significant pressure of work and he may be unable to cope. He however also mentioned that he does feel bad that he is not able to support his team members in what is the busiest time of the year.

Rather than signing him off sick, Dr Azzopardi asks him whether he feels that he would be able to work if he was doing half days or alternate days? Sateesh says he is unsure his manager would like him to be doing less hours when his team is under so much pressure. Dr Azzopardi is supportive and encourages Sateesh to contact his employer and discuss altered work arrangements. He signs the note with ‘may be fit for work’ and ticks altered work arrangements and phased return options on the fit note. Dr Azzopardi also adds further notes in the comments box

‘The patient wants to return to work but feels he may be unable to cope due to increased workload during this period. A phased return with reduced hours and workload may be helpful to achieve sustainable return to work’.

Sateesh then has a meeting with his team manager who reviews the fit note advice from GP. He agrees with Sateesh that it is very busy time for the team and they would certainly welcome any input that Sateesh is able to provide. They agree on phased return working half days and returning to full time work within 6 weeks. He also suggests that Sateesh doesn’t undertake the more stressful client facing work during the period of his phased return. He also arranged a weekly review with Sateesh to check how he was coping. At the end of 6 weeks, Sateesh felt re-integrated in the team. His team manager was appreciative of Sateesh working with the team during the busiest phase of the year. Sateesh has received the appointment for his counselling assessment for which Dr Azzopardihad referred him. His team manager allows Sateesh to use flexitime to attend appointments on the day of his counselling session.

Summary:
As Sateesh had asked for a fit note for his ongoing episode of anxiety and stress, if Dr Azzopardi had not approached the subject of working reduced hours, it is likely that he would have been signed off work for another 4-6 weeks. This would then have placed him at risk of long-term absence, and the damaging consequences of this for him. However, through proactive discussion, Dr Azzopardi was able to encourage Sateesh to consider the reasons for his stress, and to take control of this by means of a discussion on a phased return. Considering the heavy workload on his team in his absence, the team manager was appreciative of Sateesh taking up at least some of the workload off his colleagues. Staying off work for longer would not have resolved this workplace stress issue, and may have made it more diffcult for him to return, for example due to feelings of letting his colleagues down at this busy time.

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Resources

 

Organisations

https://www.nhshealthatwork.co.uk/images/library/files/Government%20policy/Mental_Health_Adjustments_Guidance_May_2012.pdf

https://www.iosh.co.uk/workingwell

  • mentalhealth.org.uk

Condition Specific Charities

Other learning resources

 

PHE  BITC Employer Toolkits

  • Mental Health Toolkit for Employers
  • MSK Health in the Workplace Toolkit for Employers
  • Suicide Prevention Toolkit for Employers
  • Suicide Postvention Toolkit for Employers
  • Sleep and Recovery Toolkit for Employers
  • Drugs, Alcohol and Tobacco Toolkit for Employers (2018)
  • Physical Activity, Diet and Healthy Weight
  • Domestic Violence Toolkit for Employers (2018)

 

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