Fit for work? Changing fit note practice among GPs

Using occupational therapists in vocational clinics in primary care: a feasibility study

Background

GPs are under considerable pressure providing routine care. However, they may not be the most appropriate professionals to manage getting patients back to work, and keeping them there.

Objective

To test the feasibility of delivering occupational therapy-led vocational clinics (OTVoc) to provide return to work advice and support for people with musculoskeletal conditions and mental health problems, in primary care.

Methods

Prospective mixed methods study in two primary care centres (eight GP surgeries). We collected anonymised service level data on all patients receiving OTVoc. Next, patient participants who met inclusion criteria and consented, undertook baseline and 3-month follow-up assessments. Interviews were also conducted to explore stakeholders’ views- GPs, Nurse Practitioners, Front Desk Staff, Occupational Therapists, patients and their employers about OTVoc- and included study eligibility, referral, experiences and attitudes to return to work. Data were analysed using descriptive statistics and thematic analysis.

Results

The majority of standardized measures showed some improvement over the study period: the sickness absence rate dropped from 71 to 15% and use of GP ‘fit’ notes reduced from 76 to 6%. Interview data indicated positive attitudes to OTVoc, the use of the fit note and the Allied Health Professions Health and Work Reports (AHP H&WRs). GPs felt that OTVoc reduced their workload.

Conclusion

Further research is feasible and warranted. OTVoc was positively received and stakeholders believed it was effective in getting patients back to work or preparing for their return. There was enthusiasm for extending service eligibility criteria, suggesting potential for further development and evaluation.

The Allied Health Professions Health and Work Report and the fit note: Perspectives of patients and stakeholders

Introduction

Although the role of occupational therapists in the provision of vocational support is established, there has been little research into their role in issuing Allied Health Professions Health and Work Reports or their potential to complete fit notes.

Method

Employed patients ( n = 14) and stakeholders ( n = 12) took part in semi-structured telephone interviews and were questioned about occupational therapy-run vocational clinics, experiences of the Allied Health Professions Health and Work Reports and their views of occupational therapists completing fit notes.

Results

Most interviewees saw the Allied Health Professions Health and Work Report as a valuable tool in affecting return to work and even employers with access to in-house occupational health predominantly found it useful in corroborating recommendations. There was consensus, amongst patients and stakeholders, that completion of the fit note by the occupational therapist could reduce the burden on the general practitioner, and potentially provide more in-depth advice via the ‘may be fit’ option. However, stakeholders strongly believed that the profile of the Allied Health Professions Health and Work Report needed to be raised nationally.

Conclusion

The potential value of Allied Health Professions Health and Work Reports in primary care is recognised. However, in order to maximise this, its profile and utility needs to be raised nationally as a matter of urgency. There was also support for occupational therapists completing fit notes.

The use of an e-learning module on return to work advice for physiotherapists - A prospective cohort study

Background: Nonspecific low back pain (LBP) can progress to chronic disability and prolonged absence from work. Despite clinical and professional guidelines, physiotherapists often fail to address return to work outcomes. Aims: The aim of this exploratory study was to determine whether an e-learning resource tailored to physiotherapy practice could affect physiotherapists' attitudes and beliefs regarding return to work advice for their patients. Design: A prospective interventional cohort study (pilot). Methods: Participants were recruited via the Chartered Society of Physiotherapy website. Responses on a clinical vignette, the Health Care Providers' Pain and Impairment Scale (HC-Pairs), and the Behavioral Constructs Questionnaire (BCQ) were collected online at baseline (Q1) and 2-months post-intervention (Q2). Results: Fifty-four physiotherapists completed Q1 and the response rate for Q2 was 44/54 (81%). Changes in the degree of agreement with guidelines indicated that the intervention made an impact on respondents (kappa 0.345; p = 0.003). HC-Pairs and BCQ results showed a nonstatistically significant trend toward the target behavior. Conclusions: There is a need for interventions to improve adherence with advice for return to work following nonspecific LBP. An e-learning tool for physiotherapists on advising patients regarding return to work has potential to positively affect self-reported clinical behavior.

Recording occupation in general practice--a second cycle audit

BACKGROUND

An audit of working age patients' records in two Cornish general practices in 2012 found infrequent and inconsistent recording of patients' occupations. A concurrent survey of general practitioners (GPs) in Cornwall found that a majority of them believed it was important to do so.

AIMS

To review occupation recording in the same practices a year later and to audit a third practice, following the introduction of the electronic fit note. To repeat the survey of attitudes to recording occupation in GPs in Cornwall.

METHODS

We manually checked 300 randomly selected patient records in Practice A and electronically searched all records of working age patients (aged 16-65 years) in Practices B and C for recorded occupation. We sent an electronic survey of attitudes to recording occupation to 202 GPs in Cornwall.

RESULTS

Recording of occupation increased from 17 to 30% of records (χ(2) = 15, P < 0.001) in Practice A and from 12 to 14% (χ(2) = 16.5, P < 0.001) in Practice B. In Practice C, 1% of records had occupation recorded and coded. The proportion of GPs in Cornwall who said that it is important to records patients' occupation increased from 70 to 90% (Fisher's exact statistic 0.01, P < 0.05).

CONCLUSIONS

Recording of patients' occupation increased in both practices from 2012 to 2013, but remains infrequent and inconsistent and the very low levels in a third practice not previously audited is of concern.

Perceptions of health professionals towards the management of back pain in the context of work: a qualitative study

Background

Musculoskeletal complaints have a significant impact on work in terms of reduced productivity, sickness absence and long term incapacity for work. This study sought to explore GPs’ and physiotherapists’ perceptions of sickness certification in patients with musculoskeletal problems.

Methods

Eleven (11) GPs were sampled from an existing general practice survey, and six (6) physiotherapists were selected randomly using ‘snowball’ sampling techniques, through established contacts in local physiotherapy departments. Semi-structured qualitative interviews were conducted with respondents lasting up to 30 minutes. The interviews were audio recorded and transcribed verbatim, following which they were coded using N-Vivo qualitative software and analysed thematically using the constant comparative methodology, where themes were identified and contrasted between and within both groups of respondents.

Results

Three themes were identified from the analysis: 1) Approaches to evaluating patients’ work problems 2) Perceived ability to manage ‘work and pain’, and 3) Policies and penalties in the work-place. First, physiotherapists routinely asked patients about their job and work difficulties using a structured (protocol-driven) approach, whilst GPs rarely used such structured measures and were less likely to enquire about patients’ work situation. Second, return to work assessments revealed a tension between GPs’ gatekeeper and patient advocacy roles, often resolved in favour of patients’ concerns and needs. Some physiotherapists perceived that GPs’ decisions could be influenced by patients’ demand for a sick certificate and their close relationship with patients made them vulnerable to manipulation. Third, the workplace was considered to be a specific source of strain for patients acting as a barrier to work resumption, and over which GPs and physiotherapists could exercise only limited control.

Conclusion

We conclude that healthcare professionals need to take account of patients’ work difficulties, their own perceived ability to offer effective guidance, and consider the ‘receptivity’ of employment contexts to patients’ work problems, in order to ensure a smooth transition back to work.

How do GPs complete fit note comments?

BACKGROUND

The 'fit note' was introduced in the UK in April 2010, to facilitate return to work (RTW). However, no research to date has reported on how general practitioners (GPs) complete the comments section of the fit note.

AIMS

To investigate the content of GPs' comments in a sample of actual fit notes.

METHODS

Data were collected in a service evaluation of fit notes issued by a regular general practice and those issued by a fit for work service (FFWS), where the fit notes for patients using the service are signed by GPs who have completed or are studying for a Diploma in Occupational Medicine. Content analysis was conducted on the fit note comments.

RESULTS

There were 1212 fit notes available for analysis. Seven hundred and twelve were issued by the general practice and 500 by the FFWS. The FFWS made comments in 98% of those who may be fit and 90% of those not fit against 72% and 12%, respectively, for comments by the general practice. Fourteen different categories were identified in the comments. Most comments made some reference to RTW but few described the functional effects of the patient's condition. Comments frequently covered more than one category and appeared to be serving a number of different purposes.

CONCLUSIONS

There was a wide variety in how the comments section was completed, and GPs were not completing the fit note as intended. The information provided may require improvement if it is to be useful to employers.