Sick of Fit Notes?

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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

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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

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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

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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).

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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)

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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.

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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
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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)

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But
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And its a big but..

• There were several provisos

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Work has to be safe

• Physically

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Provisos

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

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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)
• Waddell and Burton (2006)

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Unemployment

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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)

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Re-employment

• Improved self esteem
• Improved general and mental health
• Reduced psychological distress and minor
  psychiatric morbidity
• Waddell and Burton (2006)

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City and Guilds Career Happiness Index 2012
Happiest workers were gardeners and florists
(87) (65doctors were happy)! Happiest working
age was over 56
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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)

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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.
  

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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)

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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.

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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

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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.

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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

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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.

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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).

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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.

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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 patients
  wellbeing or compromise your patients position
  with their employer. A less precise diagnosis is
  the done thing.

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Why is there nowhere to put, This patient is fit
for work?
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To show you.

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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

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What should I put in the bit about may be
suitable for work if..

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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

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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)

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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)

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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.

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Work Capability Assessment

• Performed by Atos
• Newcastle carried out at Arden House

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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

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How can this be done without medical records?

• Impairment
• Disability

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

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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

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Examination

• Demonstration
• Observed behaviour

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Work capability Assessment (continued)

• Choice of descriptors
• Justification
• Non functional descriptors
• Support group justification
• Personal statement summary
• Prognosis

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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

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Support group

• Work related activities and being left alone
• Its something of a misnomer.

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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)

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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?

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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

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Take Home Message 2 letters of support

• Its up to you but you cant go wrong with
  providing facts.

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Failed Appeals

• You say Im fit for work but my GP WHO KNOWS ME
  BEST says Im 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. its a matter for
  their MP)

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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
• Disability Living Allowance (DLA)

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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

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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.

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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)

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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.

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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.

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Take home message 3

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

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The trouble with DLA

• Largely unchanged for 20 years
• Annual cost 12.6 billion
• Around half of awards are made without any
  medical evidence.

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DLA time remaining

• Time Remaining 5 months (although there will be
  a lengthy conversion phase)
• Personal Independence Payment

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Take home messages - reminder

• Work (generally) is good for you.
• When asked to provide letters / information you
  cant go wrong with facts.
• DLA is nothing to do with employment

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Questions