SICK OF FIT NOTES? Dr Emma Lackey GP and The Department of Justice (Medically Qualified Member of...

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

Disability Living Allowance (DLA) – brief summary

Employment and Support Allowance 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).



Disability Living Allowance (DLA)

Is work good for you or not?

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

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……

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)

And it’s a big but…..

There were several provisos……

Work has to be safe

Physically

Provisos

Various psychosocial aspects of work can also be hazardous and pose a risk to health.

Provisos

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)


Unemployment

Unemployment (even when a health selection effect is considered) 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

Longer off, less chance of getting back to work Strong evidence from Waddell and Burton (2006)

Re-employment

Improved self esteem Improved general and mental health Reduced psychological distress and minor

psychiatric morbidity


City and Guilds Career Happiness Index 2012

Happiest workers were gardeners and florists (87%) (65%doctors were happy)!Happiest working age was over 56

Work for sick and disabled people 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 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.


(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


How long can you put on a fit note? 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? 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?

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….

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?

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…” 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?

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?

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….

Declaring ‘fit for work…’

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…..

May be suitable for work if…. 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? 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)

ESA – how do you get it?

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

Performed by Atos Newcastle carried out at Arden House

Special conditions

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? Impairment Disability

Impairment and disability

Johnny Peacock (UK) winning Gold, 100m Paralympics 2012

Impairment and Disability

Impairment Any loss or abnormality of physiological or

anatomical structure or function (objective) 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

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

Demonstration Observed behaviour

Work capability Assessment (continued) Choice of descriptors Justification Non functional descriptors Support group justification Personal statement summary Prognosis

Descriptors

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 Non functional descriptors - Regulation 29

‘Support group’

Work related activities and being left alone

It’s something of a misnomer.


(ESA) Is work good for you? Fit notes ESA work capability Assessment and ATOS ESA appeals process ESA and JSA – monetary issues


Appeal Process

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 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 It’s up to you – but you can’t go wrong

with providing facts.

Failed Appeals

“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)


(ESA) Is work good for you? Fit notes ESA work capability assessment and ATOS ESA appeals process ESA JSA – monetary issues


Money involved- April 2012

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

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.


(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) 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

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

DLA is nothing to do with work or capability for work or employment.

The trouble with DLA…

Largely unchanged for 20 years… Annual cost 12.6 billion Around half of awards are made without

any medical evidence.

DLA time remaining

Time Remaining – 5 months (although there will be a lengthy conversion phase)

Personal Independence Payment

Take home messages - reminder 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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