Rehabilitation for Work Matters

Jim Ford, Gordon Parker, Fiona Ford, Diana Kloss, Simon Pickvance, Philip Sawney

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781857757866
• eBook ISBN: 9781315344973
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

A working understanding of medical ethics is becoming ever more important to all practising doctors. There are many ethical issues which present often unexpectedly to healthcare professionals which can seem impossible to resolve. This is an introductory text for everyday general practice. Key issues and relevant legal aspects are illustrated with examples and case histories and the book is structured so particular topics can be found with ease. For added benefit chapters have pointers for further reflection and analysis references to journal articles and useful reading lists. The book can be used as a resource for group discussion or by individual general practitioners including GP registrars and their trainers.

CHAPTER 1

Introduction

SICKNESS CERTIFICATION: A GOOD PLACE TO START?

Certification of sickness for employers is a task which has been the responsibility of GPs for nearly a century, and is the one aspect of their work relating to workplace health that they cannot avoid. There is no indication that it is a task which is likely to be removed. Rather, if anything, we might expect the clinical governance process which has improved the rest of primary care to spread into this area. It must thus be judged as a core task in primary care, so this is a good place to begin a book about rehabilitation and return to work, so that the wider potential for health improvement which the invitation to participate positively in the certification process offers can be explored. Chapter 4 will examine certification in greater depth. The rest of this chapter will consider what we actually mean by the words used in this field.

What is certification?

Sickness certification fulfils a number of roles in working-age society. It provides a universal structure which forces an employee who feels unfit to attend their primary care practitioner at around the time when a simple illness should be resolving. It also provides a form of attestation that the person is too ill to attend work, which enables an employer to accept that the employee is physically or mentally unable to work. Some employers might judge that, in requiring the effort to attend a GP, it also disincentives absence. However, other employers feel that GP certificates legitimise trivial causes of absence. The fact that certification results in a paper transaction between employer, employee and GP is often forgotten, for this creates opportunities for further communication that are rarely exploited, but which will be explored in this book.

Duty of certification

Many GPs nonetheless remain deeply uneasy about the task of certification, and complain that it introduces role conflict into their duty as patient advocates. However, good patient advocacy surely requires that patients are made fully aware of the possible long-term health outcomes of their behaviour. Patients who may be struggling with the effects on their working ability of a new medical condition, such as diabetes, or with new working practices, such as being located in a call centre, may be desperate for the respite of a couple of weeks ‘on the sick.’ But will things be any different when they return after this time? Probably not, and on return there may be some considerable catching up to do, if only with the office politics. Inevitably, there will be a temptation to ask for another note, and then another, and who can blame a GP for giving a longer duration?

‘Diagnoses’ on sick notes

It is often clear that the diagnosis which is written on a certificate has little to do with what is actually happening to the employee. One of the most difficult areas concerns the need for a person to stay off sick because they are ‘required at home’ to provide support for a partner with a serious illness or for a handicapped child. Individuals who enjoy generous sick pay may be tempted to send in a sick note when they should really be requesting (unpaid) compassionate leave. However, their employer is not funded to cover such lengthy absences; the consequential costs will be carried by the whole organisation, but in practice the burden of replacing their duties will fall on their colleagues. And when they do return to work, they may not be surprised to witness one of their colleagues subsequently producing a sick note for ‘stress’! In the longer term, such absence will affect the efficiency of their unit, and might lead to outsourcing to an external private provider who is unlikely to accept such practice.

THE COST OF ABSENCE

We are frequently reminded of the cost of sickness absence to employers: £13.4 billion a year in salaries alone, according to the CBI. But the greatest burden is not on the employer but on the colleagues of the absent employee, or indeed on the individual returning from sickness.

When businesses claim they are losing huge sums through sickness absence, it assumes that productivity would be dramatically improved if all workers attended 100% of their contracted hours. The reality in most situations, however, is that other workers pick up the work from absent colleagues, frequently through unpaid overtime and lost breaks. One survey of UK workers found that two-thirds stay late at least once a week, half take work home and two-fifths have to work at weekends at least some of the time – simply because of the demands placed on them. Organisations have been trimmed over recent years to achieve maximum output from the smallest number of employees, but because jobs are not designed to allow for sickness absence, most short-term labour shortages are absorbed not by the employer’s purse but by an already stretched workforce. And the consequences of this extra workload: longer hours, greater pressure and increased demands on workers already at elevated risk to their health from work-related stress.

For some people, however, being absent means work piling up unattended. Many people will have experienced the post-holiday dread: countless emails, letters, voicemails and tasks with urgent deadlines. Sadly, many people off sick for prolonged periods will have that very same feeling – nothing has been done to ease their workload in their absence. If the cause of their sickness in the first place was work-related stress, what better way to hamper their return?

John Ballard

John Ballard is director of the At Work Partnership and editor of the journal Occupational Health [at Work].

Duration of sick notes

It is tempting for a busy GP, when faced with repeated requests for sick notes from a patient whom they are expecting to be recovering, to issue a certificate of long duration such as 8 or 13 weeks or even ‘ufn’ (until further notice). However, government statistics suggest that many long absentees fail to return to work altogether. Providing shorter certificates enables regular reviews and creates opportunities for encouraging the person to return to meaningful activity, as a prelude to work. Such investment by the GP may be wearing and repetitive, but allowing the patient to lapse into economic inactivity will gift them plenty of time and opportunity to make many appointments in future!

Health risks of unemployment

Research suggests that being workless incurs a risk to health equivalent to smoking 200 cigarettes per day. Health risks and life expectancy are worse than those for many killer diseases, and there are greater risks attached to worklessness than to most dangerous jobs, even those in construction or the North Sea. In particular, the general suicide rate is increased sixfold in the longer-term unemployed, and in young men who have been unemployed for just 6 months it is increased 40-fold.

Economic inactivity and poverty

Spending the rest of one’s working life on benefits inevitably leads to lower prosperity, and possibly also poverty and ill health. Equally, although a ‘full’ early pension, without actuarial reduction and with extra years granted for ill health, may seem alluring for the declining number of employees who are still entitled to a defined benefit pension, it may be too late before the person realises that, at best, this actually means half-pay for the remainder of their life, with no increases due to promotion or seniority and further growth determined by the stock market or the retail price index!

WHAT IS REHABILITATION FOR WORK?

Rehabilitation for work is rehabilitation that is orientated towards the goal of achieving gainful occupation and economic independence in an impaired, ill, injured or disabled person of working age. It is a modern evolution of vocational rehabilitation, with a stronger emphasis on achieving sustainable employment in the open labour market as the ultimate goal. Traditional vocational rehabilitation was developed with ex-servicemen after the Second World War, and continued up to the 1970s using a medical model for rehabilitation, with sheltered workshops and other placements outside the open market for employment.

Nowadays, sheltered workshops are exceptional, and even quite severely disabled people work in mainstream jobs with support and encouragement. The fighter pilot, Douglas Bader, is legendary in this context. After losing both of his legs in action he returned to flying Spitfires, and when he was captured, his captors had to remove his artificial legs to prevent his repeated attempts to escape. In modern times the Cambridge physicist, Professor Stephen Hawking, continues to achieve international acclaim as a physicist despite severe disablement with motor neuron disease. For anybody studying successful adaptation to disability, Professor Hawking’s personal website (www.hawking.org.uk) is worth more than a passing glance to see what it feels like to have a successful career with a profound disability.

Although return to paid work remains the ultimate goal, there are a number of intermediate stops along the way, such as training and voluntary work. The word ‘rehabilitation’ implies an active process of recovery to a previous state. However, the same word is commonly also applied to people who are not recovering, but who instead are trying to overcome the disabling effects of an inherited condition resulting in impairment, such as learning disability or spina bifida.

There are two other useful definitions of rehabilitation used in this field which illustrate the wider stakeholders. A joint working group of the Trades Union Congress and the Association of British Insurers set out that ‘Rehabilitation should restore a person who has been injured or suffered an illness to as productive and as independent a lifestyle as possible through the use of medical, functional and vocational interventions.’ The British Society of Rehabilitation Medicine describes rehabilitation as ‘A process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimal physical, psychological and social function.’

WHAT IS DISABILITY?

Disability means difficulties encountered by an individual when performing particular functions. These may be physical and/or mental impairments. It implies nothing about causation or diagnosis, but is concerned with the limitation of activities and restriction of participation in people with physical and/or mental conditions or impairments – that is, it is an entirely functional concept. Disabled people often prefer to describe their disability not in medical language, but in terms which reflect the extent to which the outside world has adapted to their needs. This is described as the social model of disability.

WHAT IS IMPAIRMENT?

Impairment is the underlying change in the mind or body, which causes the disability. For example, difficulty in getting about might be caused by a hemiplegia, perhaps due to a stroke or a brain injury. An impairment is usually described in medical terms, and can be caused by an underlying medical condition or an injury. It is thus a significant, demonstrable deviation or loss of body structure or function, sometimes referred to as ‘loss of faculty.’

WHAT IS INCAPACITY?

Incapacity means a lack of capability of an individual to undertake a set of tasks which would be considered normal for a person of their age or background. For example, a person who is suffering from a mental health condition may lack sufficient mental capacity to sign documents. In the context of rehabilitation for work, when we talk about incapacity, we normally mean incapacity for work – that is, reduced capacity for and functioning at work (i.e. for participating in economically gainful activity). It can be difficult to distinguish between ‘capacity’ and ‘performance’ where the latter also depends on motivation and effort, which therefore complicates the assessment of incapacity, as we shall see later.

WHY THESE TERMS MATTER: OBJECTIVITY AND SUBJECTIVITY

In the past, these terms have been used quite loosely, and even interchangeably. However, the modern understanding about different models of disability and the context of assessment means that we need to treat the terms more precisely, especially as medical decisions often result in resource consequences elsewhere. For this reason they are defined in UK law for Social Security terms. The summary table which follows is repeated again in Chapter 9. Note that the terms ‘disease’, ‘impairment’ and ‘injury’ are objective, implying that impartial evidence exists to support their existence. By contrast, ‘illness’ and ‘disability’ are subjective concepts which may vary from person to person. Both subjective and objective factors will influence the outcome of incapacity or sickness in an individual.

THE DISTINCTION BETWEEN KEY TERMS

Disease is objective, medically diagnosed pathology (i.e. it is a disorder of structure or function of the human organism).

Impairment is significant, demonstrable deviation or loss of body structure or function, sometimes referred to as ‘loss of faculty.’

Symptoms are bodily or mental sensations that reach consciousness (e.g. aches, pains, fatigue, breathlessness, anxiety).

Illness is the subjective feeling of being unwell (i.e. it is an internal, personal experience).

Disability is the limitation of activities and restriction of participation in people with physical and/or mental conditions or impairments.

Sickness, or the sick role, is a social status accorded to the ill person by society, with exemption from normal social roles and carrying specific rights and responsibilities (i.e. it is an external, social phenomenon).

Incapacity is reduced capacity for and functioning at work. It is difficult to distinguish between ‘capacity’ and ‘performance’ where the latter also depends on motivation and effort.

THE BIOMEDICAL MODEL

As physicians we are very familiar with the biomedical model, namely the presentation of symptoms, and diagnosis by history-taking examination and investigations, leading to commencement of treatment and recovery. However, we observe that despite scientific rigour, not everyone gets better, and symptoms may be misleading, especially when they are subjective and the absence of objective investigations and signs does not mean that there is no underlying impairment – it may just be that it has not been diagnosed yet. The Cartesian model of pain as a manifestation of underlying disorder similarly ignores the enduring effect of pain once the cause has been determined to be less than serious.

COMMON HEALTH CONDITIONS AND WORK

Common health conditions, such as ischaemic heart disease, high blood pressure, diabetes, anxiety/depression, chronic low back pain and othe...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Preface
• About the authors
• Acknowledgements
• 1 Introduction
• 2 Why does rehabilitation for work matter?
• 3 Detecting and dealing with the barriers to return to work
• 4 Primary care and rehabilitation for work
• 5 Perspective of a lay adviser in occupational health
• 6 Assessment of fitness for work in practice
• 7 Who else is involved, what do they do, and how can you engage them?
• 8 Specific causes of absence: case discussions
• 9 The UK social security system and rehabilitation
• 10 The legal framework
• Appendix
• Index