Transcript Sick of Fit Notes?

SICK OF FIT NOTES?
Dr Emma Lackey GP and The Department of Justice (Medically Qualified Member of First Tier Social
Entitlement Chamber)
Dr Jan Sturman GP and Medical Disability Analyst for ATOS
Disclaimer!

Although I do work for the Department of Justice,
this presentation is my own and is not done on their
behalf – opinions and mistakes are my own…
What we are covering today….

Employment and Support Allowance (ESA)
 Is
work good for you?
 Fit notes
 ESA work capability assessment and ATOS
 ESA appeals process
 ESA and JSA – monetary issues
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Disability Living Allowance (DLA) – brief summary
Employment and Support Allowance
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Ethos of it ESA: Intended to provide income
replacement for people who are unable to work
because of illness or disability.
Commenced 27 October 2008
Replaces Incapacity Benefit, severe disablement
allowance and income support paid on the grounds
of incapacity (migration period).
What we are covering today….

Employment and Support Allowance (ESA)
 Is
work good for you?
 Fit notes
 ESA work capability assessment and ATOS
 ESA appeals process
 ESA and JSA – monetary issues

Disability Living Allowance (DLA)
Is work good for you or not?
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Asked by the Department of Work and Pensions in
2005 as part of their Health, Work and Well-being
Strategy.
Independent Review commissioned – done by
Waddell and Burton.
246 pages later the question was answered in a
green paper….
Drum Roll
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Work IS generally good for health and wellbeing.
Waddell and Burton (2006) “Is work good for your health
and well being?”
Proposals were laid out in a white paper written by DWP, DH
and health and safety executive
Benefits of work……
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Generally the most important means of obtaining
adequate economic resources (i.e. we do it for the
money)
Work provides psychosocial needs, identity, social
roles and social status.
Waddell and Burton (2006)
But
And it’s a big but…..
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There were several provisos……
Work has to be safe
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Physically
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Provisos
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Various psychosocial aspects of work can also be
hazardous and pose a risk to health.
Provisos
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Findings were a group effect – a minority of people
may experience contrary health effects from work.
Beneficial health effects do depend on the nature
and quality of work (i.e. work should be safe and
accommodating)
Waddell and Burton (2006)
Unemployment
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Unemployment (even when a health
selection effect is considered)
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Higher mortality
Poorer general health, longstanding illness
Poorer mental health, psychological distress, minor
psychological/psychiatric morbidity
Higher medical consultation, medication consumption
and higher hospital admission rates
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Longer off, less chance of getting back to work
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Strong evidence from Waddell and Burton (2006)
Re-employment
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Improved self esteem
Improved general and mental health
Reduced psychological distress and minor psychiatric
morbidity
Waddell and Burton (2006)
City and Guilds Career Happiness
Index 2012
Happiest workers were gardeners and florists (87%) (65%doctors were
happy)!
Work for sick and disabled people
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Is therapeutic, promotes recovery and rehabilitation
Leads to better health outcomes
Minimizes harmful physical, mental and social
effects of long-term sick absence
Reduces risk of long term incapacity
Promotes participation in society and independence
Reduces poverty and improves quality of life and
well-being
Waddell and Burton (2006)
Take home message number 1
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Overall, the beneficial effects of work outweigh the
risks of work, and are greater than the harmful
effects of long-term unemployment or prolonged
sickness absence.
Work is generally good for health and well-being.
What we are covering today….

Employment and Support Allowance (ESA)
 Is
work good for you?
 Fit notes – introduced 6th April 2010
 ESA work capability assessment and ATOS
 ESA appeals process
 ESA and JSA – monetary issues

Disability Living Allowance (DLA)
How long can you put on a fit note?
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During the first 6 months of sickness this can be up
to a maximum of 3 months. After the first six 6
months of incapacity a statement can be issued for
any clinically appropriate period up to ‘an
indefinite period.’
Can I issue a statement from a telephone consult
or without any patient contact?
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Yes you record the date on which you undertake or
undertook:
A
face to face consultation
 A telephone consultation.
 The consideration of a written report from another
doctor or registered healthcare professional
Can they be backdated?
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A statement of fitness to work can only be issued
for a backdated period when it is based on a
previous assessment.
An assessment is defined as the date you either had
a face to face consult, a telephone consult or
considered a report from another doctor or
registered healthcare professional. You can issue a
statement after this but not before.
Backdating continued….
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The DWP recognise there are some situations where your patient
may ask for medical evidence to cover a backdated period for
which there has not been a previous assessment. For example if they
did not get a med 3 at hospital discharge or a previous consult with
another GP.
In these situations you cannot issue a Med 3 for the back dated
period. However in order to be helpful for your patient you may
wish to, either in the comments box or in a separate letter, provide
advice that the patient was not fit for work for an earlier period.
You should ensure you have the appropriate information and
evidence to justify this advice – generally via a report or patient
record. Employers and DWP can accept this advice as strong
evidence for fitness to work for social security and Statutory sick
pay purposes.
BB
Can I issue duplicate statements to a patient with
2 part time jobs?
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No. You can only issue a duplicate Med 3 if the
original statement has been lost. You should clearly
mark it “Duplicate”. Advise people with more than
one employer to submit the statement to their main
employer, who can note the details of the advice
you have given. They can then present the statement
to their second employer.
“The job centre told me I need/must
have one…”
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What the Jobcentre may have said, “To be eligible
for ESA you need a sick note.”
Or if the patient tells the job centre they have a
health problem affecting work, the response may
be “you would need a fit note from your GP
regarding that.”
Sometimes I think things change in translation.
The decision re issuing the statement is a statutory
obligation of the doctor (and only a registered
medical practitioner).
I miss the RM7 can I still use it?
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The RM7 has been withdrawn from use. It was really
a request for an independent medical assessment of
a patient and the idea is now that the ATOS work
capability assessment is done much earlier (at 3
months), so one is done anyway now.
Can I put a white lie in the diagnosis
box?
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The diagnosis should be as accurate as possible
unless you consider that providing a precise
diagnosis would be harmful to your patient’s
wellbeing or compromise your patient’s position with
their employer. A less precise diagnosis is the done
thing.
Why is there nowhere to put, “This
patient is fit for work’?
To show you….
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Declaring ‘fit for work…’
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From 6th April 2010 certification changed and the
box ‘need not refrain from work’ disappeared.
It generated a common myth that some patient or
employers felt it was needed this as a statement. In
the cases where one is required (e.g. for LGV/PCV
drivers) there is an existing procedure.
If an employer feels they require such advice they
can get it a GP or occy health specialist via a
private arrangement…
What should I put in the bit about may
be suitable for work if…..
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May be suitable for work if….
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Try not to be too prescriptive….
E.g. – ‘cannot sit for long periods’ is better than ‘should
be provided with a better chair’
In travel related anxiety ‘avoiding travel in peak hours’
is better than ‘should work between 10am and 4 pm.’
Consider recommending an occupational health
assessment.
If the employer cannot provide the conditions (phased
return amended hours etc) they can use the statement as
you had advised ‘not fit for work.’
Recent HR study showed that between 38-70% had
noted GPs did not comment
What about new electronic fit notes?
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Roll out begins in July 2012 and should be
complete by early 2013 (?)
No changes – just that it will print electronically –
but handwritten notes will still be available (e.g. for
home visits)
Electronic notes will not be available for hospital
doctors.
Audit use (anonymised)
What we are covering today….

Employment and Support Allowance (ESA)
 Is
work good for you?
 Fit notes
 ESA work capability assessment and ATOS
 ESA appeals process
 ESA and JSA – monetary issues

Disability Living Allowance (DLA)
ESA – how do you get it?
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Fit note (med3) as not fit for work from GP
(Assessment phase covers first 13 weeks)
Then fill in an ESA50 form from job centre
Then called for a Work Capability Assessment.
Decision maker at the Department for Work and
Pensions informs client of outcome.
Right to appeal goes to the Department of Justice.
Appeal is done either as a review of paperwork or
with the client present.
Work Capability Assessment
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Performed by Atos
Newcastle carried out at Arden House
Special conditions
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Terminally ill
Some chemotherapy
carrying or having had contact with certain diseases
covered by public health regulations
Hospital in-patients (including residential detox)
Pregnancy - conditions apply
How can this be done without medical
records?
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Impairment
Disability
Impairment and disability
Johnny Peacock (UK) winning Gold, 100m Paralympics 2012
Impairment and Disability
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Impairment
 Any
loss or abnormality of physiological or anatomical
structure or function (objective)
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Disability
 Any
restriction or lack of ability to perform an activity
 Pain and disability are subjective
A
disability examination is very different from a
diagnostic examination
Work Capability Assessment
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ESA50 form and GP correspondence letters in file
List conditions – duration, history, specialists, treatments,
current symptoms and frequency
Drug and alcohol issues
Medication and side effects
Social history - cohabitants and accommodation type
Occupational history and reason for leaving and
current work / study
Typical day
Examination
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Demonstration
Observed behaviour
Work capability Assessment (continued)
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Choice of descriptors
Justification
Non functional descriptors
Support group justification
Personal statement summary
Prognosis
Descriptors
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17 descriptors in total – see handout
You need 15 points to receive ESA (take the highest
points in each descriptor)
Caution advised – you need to read them very
carefully and those applying them have specialised
(extensive) training - for example
Descriptor 2
 Application when drunk
 Going out accompanied – necessity or choice?
 Beyond reasonable doubt or balance of probability
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Non functional descriptors - Regulation 29
‘Support group’
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Work related activities and being left alone
It’s something of a misnomer.
What we are covering today….

Employment and Support Allowance (ESA)
 Is
work good for you?
 Fit notes
 ESA work capability Assessment and ATOS
 ESA appeals process
 ESA and JSA – monetary issues

Disability Living Allowance (DLA)
Appeal Process
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60% fit for work (by DWP) from WCA
41% of those appeal and 38% of those are upheld
What happens at an appeal?
Can you appeal again?
GP Issues – letters of support
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My patient has asked for a letter of support and I
do support them, what can I say that helps?
My patient has asked for a letter of support but I
suspect they may actually be capable of work…
On advice from the BMA GPs have no contractual
obligation to provide evidence
Take Home Message 2: letters of
support
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It’s up to you – but you can’t go wrong with
providing facts.
Failed Appeals
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“You say I’m fit for work but my GP WHO KNOWS
ME BEST says I’m not fit for work.”
New sick notes should only be issued if there is a
new condition or a significant change in an existing
condition.
Decision makers and appeal processes are there to
apply the law.
Disagreeing with the law is a matter for
politicians/parliament (i.e. it’s a matter for their MP)
What we are covering today….

Employment and Support Allowance (ESA)
 Is
work good for you?
 Fit notes
 ESA work capability assessment and ATOS
 ESA appeals process
 ESA JSA – monetary issues
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Disability Living Allowance (DLA)
Money involved- April 2012
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JSA – many rates to compare – aged 25 or over,
no children and not a couple £71/week
ESA
 Income
related- aged 25 not a couple and no children
£71/wk
 Contributions related – assessment phase £71/wk then
additional WRAC £28.15/wk
 Contributions related support group - £71/wk plus
£34.05/wk
Moving the goal posts
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First adjustment in 27th October 2008 ESA
introduced
Change of descriptors 28th March 2011
Closure of doors – 30th April 2012 – time limiting
contributions based ESA WRAG to 365 days.
What we are covering today….

Employment and Support Allowance (ESA)
 Is
work good for you?
 Fit notes
 ESA work capability Assessment and ATOS
 ESA appeals process – common difficult cases
 ESA and JSA – monetary issues

Disability Living Allowance (DLA)
Disability Living Allowance (DLA)
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Ethos – this is for people who have a disability and
as a result need help with either getting around
(mobility component) or personal care (care
component)
It covers washing, dressing, bathing, supervision and
getting around. It does not include help with
activities such as shopping or housework.
DLA
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Mobility component (higher rate, lower rate)
Care component (higher, middle and lower rate)
You can have mobility or care or both
Once over 65 – it switches to Attendance Allowance
which has no mobility component.
Take home message 3
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DLA is nothing to do with work or capability for
work or employment.
The trouble with DLA…
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Largely unchanged for 20 years…
Annual cost 12.6 billion
Around half of awards are made without any
medical evidence.
DLA time remaining
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Time Remaining – 5 months (although there will be a
lengthy conversion phase)
Personal Independence Payment
Take home messages - reminder
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Work (generally) is good for you.
When asked to provide letters / information – you
can’t go wrong with facts.
DLA is nothing to do with employment
Questions
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