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Br J Gen Pract. 2010 April 1; 60(573): 245–250.
PMCID: PMC2845487

Working towards a ‘fit note’: an experimental vignette survey of GPs

Anna Sallis, BSc, MSc, Health Psychologist in Training and Richard Birkin, CPsychol (Occupational), Registered Psychologist
Occupational and Health Psychology Services, Health, Work and Wellbeing Directorate, Department for Work and Pensions, London
Fehmidah Munir, PhD, CPsychol (Health), Senior Lecturer in Psychology

Abstract

Background

The Department for Work and Pensions (DWP) has designed a trial medical statement.

Aim

To compare fitness for work assessment outcomes and written advice across current and trial medical statements. To examine the use of and suggestions to improve the trial medical statement.

Design of study

Comparative study with a two-way mixed design using questionnaire-based vignettes presenting GPs with three hypothetical sick leave cases (back pain, depression, combined back pain and depression) and medical statements (current or trial). The questionnaire also gathered GP views of using the trial Med 3.

Setting

Nine primary care organisations (PCOs) in England, Scotland, and Wales.

Method

Five hundred and eighty-three GPs employed in PCOs in summer 2008 were randomised to receive a current or trial Med 3 postal questionnaire. GPs assessed vignette patients' fitness for work using the questionnaire medical statements.

Results

GPs using the trial Med 3 were less likely to advise refraining from work and more likely to provide written fitness for work advice compared to GPs using the current Med 3 form. Date sections of the trial Med 3 were used inconsistently, and a return to work date was unclear. GPs wanted further clarification of the implications of assessing a case as ‘fit for some work’ and its relationship to employers' willingness to follow GP advice about work.

Conclusion

The study indicates a revised form may reduce the number of patients advised to refrain from work and increase the provision of written fitness for work information.

Keywords: back pain, depression, family, employment, physicians, sick leave

INTRODUCTION

Each year around 350 000 people in Britain leave work to claim health-related benefits, and some 172 million lost working days are attributed to sickness absence,1 an estimated 3.5% of working hours.2 Employers find managing sickness absence challenging, and in a recent study, more than two-thirds (69%) indicated the introduction of capability-focused medical certificates would help.1 The current medical statement (Med 3) has been in use since 1948, a time when employees were expected to do a particular job and concepts about the workplace were different. Since then, the environment in which GPs provide fitness for work advice has changed. Safer workplaces followed the introduction of health and safety legislation.3 Employers now have a duty to make adjustments for disabled people, to avoid less favourable treatment and to promote equality: provisions of the Disability Discrimination Act, 1995/2005. Importantly, research evidence indicates that work is good for health,4 and healthcare profession leaders have signed a consensus statement noting the benefits of appropriate work and that remaining in or returning to work should be a measure of treatment success.5

Revision of the Med 3 has been widely discussed.610 The Black report highlighted the need for medical certification to support GPs' provision of fitness for work advice to patients and employers.6 GPs report that the current Med 3 could be improved.1113 Their suggestions include: indicating that the patient could undertake some form of work, more specific details of prognosis and return to work timing, and space to provide this information.11

How this fits in

Fitness for work assessment and return to work advice may relate to the design of the Med 3. Revision of the Med 3 has been widely discussed and healthcare profession leaders, including 15 medical Royal Colleges and Faculties, have noted work retention or return should be a measure of treatment success. This study compared the current medical statement with a trial form, designed by the Department for Work and Pensions in consultation with medical experts and employers, and indicated that GPs using the trial Med 3 were less likely to advise refraining from work and more likely to provide written fitness for work advice. The GPs surveyed identified a need to clarify the relationship between fitness for work assessment and employer willingness to follow GP advice.

In consultation with two external working groups (medical experts, employer and employee representatives), the Department for Work and Pensions (DWP) designed a new Med 3. This new form, alongside other policy initiatives, endeavours to facilitate the flow of information between GPs, patients, and employers, to help them consider earlier return to work.6,8 DWP psychologists were asked to review the revised Med 3. This study aimed to: first, compare fitness for work assessments and written fitness for work advice provided by GPs in the current and the ‘trial’ Med 3; second, examine use of trial Med 3 sections; and third, explore suggestions to improve the form.

METHOD

Design of the trial Med 3

The new trial Med 3 introduced: (i) a ‘may be fit for some work’ option; (ii) an enlarged comments section; (iii) optional ‘work solutions’: graded return to work, altered hours, amended duties, and workplace adaptations; (iv) a section to specify if and when another GP consultation is required; and (v) an expected return to work date. Sections (iv) and (v) aimed to reduce uncertainty by providing an expectation of when the patient might return to work and whether the doctor needs to see the patient again. If the doctor does not need to see the patient again, section (v) can be a closed statement similar to the current Med 3. Current statutory sick pay regulations make it possible for a patient to be issued a series of ‘open’ statements.14 In such circumstances, the employer has no ‘return to work’ information.15 Two pages of guidance described how and when the GP should complete each section of the trial Med 3 form.

Study design and interventions

An experimental questionnaire survey employed a two-factor mixed design (health condition — repeated measures and medical statement — between subjects).

The questionnaire included (a) three vignettes describing hypothetical sick leave scenarios varying in health condition: back pain, depression, and combined back pain and depression; (b) a medical statement (current or trial Med 3); (c) a multiple choice question on trial Med 3 completion time; and (d) open-ended questions about suggested changes to the trial Med 3 and help required completing it. GPs were randomised to receive a questionnaire varying in terms of (b).

Vignettes

Vignettes were designed so that all fitness for work assessments and work solutions were plausible. Previous research shows mental health conditions and musculoskeletal disorders are the most common reasons for issuing medical statements.1618 Vignettes introduced a male in his forties with a short description of his work duties and health condition (duration, symptoms, previous treatment). The back pain case described a warehouse supervisor whose job involves administration, managing a small team, regular walking, and occasional heavy lifting. The depression case described a building surveyor office worker who manages six staff with occasional site visits. The combined case was a service station retail manager whose job involves staff management, stock handling, and lifting. Patients were described as having: (i) spells of absence lasting up to 2 weeks over the previous 2 years; (ii) consulted with a GP 4 weeks previously, reporting deteriorating symptoms; (iii) been issued with a Med 3 for 4 weeks; and on its expiry (iv) presented to the GP reporting no improvement.

Sampling and recruitment

A purposive sample of primary care organisations (PCOs) in England, Scotland, and Wales provided a GP sample. In summer 2008, PCO chief executives were invited to participate and provide a database from which all practising GPs were posted an invitation letter, information sheet, questionnaire including Med 3 forms (and trial Med 3 guidance where relevant), and a prepaid envelope. Reminder letters were sent via practice managers approximately 3 weeks later.

Outcome measures

Fitness for work assessments

GPs recorded their assessments on Med 3 forms. The forms provided two (current) or three (trial) possible assessments: (i) fit to work — current Med 3 case assessed ‘need not refrain from work’ or trial Med 3 ticked ‘you are fit to work’; (ii) not fit to work — current Med 3 completed ‘you should refrain from work for/until’ or trial Med 3 ticked ‘you are not fit to work’; (iii) fit for some work — ticked, trial Med 3 form only.

Provision of written fitness for work advice

Cases were assessed as including fitness for work advice if there were one or more comments in: (i) current Med 3 ‘doctors’ remarks' section; or (ii) trial Med 3 ‘comments’ section. A diagnosis was not classified as fitness for work advice.

Work solutions (trial Med 3 only)

Four multiple choice options were used: graded returns, altered hours, amended duties, and workplace adaptations.

Date sections (trial Med 3 only)

Two sections required the GP to indicate a date or time period: one when the GP would like to see the patient again, the other when the patient is expected to return to work. Incomplete data were not scored.

Improving the trial Med 3 (trial Med 3 only)

Open-ended questions were used, where GPs could note their proposals for changes to the trial Med 3 and what would help form completion.

Completion time (trial Med 3 only)

GPs recorded on an ordinal scale, (ranging from ‘over 3 minutes less’ to ‘over 3 minutes more’) their estimate of trial Med 3 live completion time.

Analysis of data

SPSS for Windows (version 11.5) was used for statistical analysis of data. The χ2 statistic and t-tests explored differences in demographic characteristics between current and trial Med 3 groups, (two-tailed tests and results significant at P<0.001).

Data were pooled across all PCOs, and binary logistic regression used to investigate the relationship between Med 3 form and fitness for work assessment, then the presence of written fitness for work advice. To compare the number of patients advised to refrain from work across the two Med 3 forms, trial Med 3 ‘fit for work’ and ‘fit for some work’ options were combined. A score of 1 was given to trial Med 3 statements and 0 to current Med 3s. Adjustment for potential confounders did not materially affect the results; therefore, only single variable results are shown. Associations are presented as odds ratios (OR) (95% confidence intervals [CIs], P-value).

RESULTS

Profile of responders

Nine (five in England, three in Scotland, and one in Wales) of the 30 PCOs contacted participated (30%), generating 3184 GP contacts. Thirteen contacts were ineligible (absent from practice or invalid address); 583 valid questionnaires were returned (18%). Eight GPs returned incomplete forms and 48 wrote to decline participation (too busy/no time, no incentive payment, disagreement with government policies affecting GPs, a need to negotiate fitness for work decisions with the patient, and questionnaire length).

Fifty-three per cent (n = 309) of valid questionnaires were from GPs assigned the current Med 3, and 47% (n = 274) from those assigned the trial Med 3. There were no statistically significant differences in the demographic characteristics of GPs between the two Med 3 groups: average age 46 years, 51% male, 8% had an occupational health qualification, 32% were GPs for less than 10 years, 3% worked in a single-handed GP practice, 21% in a practice with two to three GPs, 30% in a practice with four to five GPs, and 46% in a practice with six or more GPs; 56% worked in an urban area, 20% in a rural area, and 22% in an inner city area.

Comparing fitness for work assessments

GPs using the trial Med 3 form were more likely to assess cases as ‘fit for work’. This applied across all three health conditions: back pain (OR) = 13.4; 95% CI = 8.9 to 20.2; P<0.001); depression (OR = 3.5; 95% CI = 2.1 to 5.8; P<0.001); and combined (OR = 5.5; 95% CI = 3.5 to 8.6; P<0.001).

GPs using the trial Med 3 assessed 70% of back pain cases as ‘fit for some work’ (Table 1), whereas 76% of the same back pain cases were advised by GPs using the current Med 3 to refrain from work. ‘Fit for some work’ was used least often in the depression case (19%). The majority of depression cases were considered ‘not fit for work’ using trial (74%) and current (91%) Med 3 forms. GPs using the current Med 3 form assessed 88% of cases with combined back pain and depression as ‘not fit for work’, compared to 58% of cases assessed this way by GPs using the trial Med 3.

Table 1
Fitness for work assessments and written advice.

GPs using the trial Med 3 form were less likely to advise patients to refrain from work, although a small proportion of cases were deemed ‘fit for work’. Taking into account the reduction in cases that were ‘fit for work’ and the decrease in cases that were ‘not fit for work’, a net increase of 15 to 44 percentage points remained across the health conditions considered ‘fit for (some) work’.

Comparing fitness for work advice

Cases with written advice in the comments section were more likely to have been assessed by GPs using the trial Med 3 form. This applied across all three health conditions: back pain (OR = 9.3; 95% CI = 6.3 to 13.6; P<0.001); depression (OR = 8.1; 95% CI = 4.9 to13.6; P<0.001); combined health condition (OR = 12.7; 95% CI = 7.9 to 20.5; P<0.001). When written advice was compared between health conditions (across both current and trial Med 3 forms) it was found that GPs were more likely to provide written fitness for work advice in the back pain case (41%), compared to the combined (27%) and depression cases (20%). This may be related to the larger number of back pain cases assessed as ‘fit for (some) work’.

Use of trial Med 3 work solutions

Altogether, 796 work solutions were suggested by GPs using the trial Med 3 (back pain n = 349; combined n = 281; and depression n = 166). In the back pain case, a work solution was suggested most frequently when GPs made a ‘fit for some work’ assessment (n = 289). Amended duties were the most commonly used option for the back pain case. Altered hours were suggested least often, regardless of assessment outcome (Table 2). The guidance advised that work solutions are used in ‘fit for some work’ assessments; however, GPs used them for the other assessments.

Table 2
Use of trial Med 3 work solutions.

Graded return was the most frequently suggested work solution for the depression case and this was used mostly when cases were ‘not fit to work’. This is the only circumstance where a work solution was used more often when a case was considered ‘not fit for work’(n = 49). In the combined health condition case, work solutions were used most frequently when the case was assessed as ‘fit for some work’. Amended duties was the most frequently suggested work solution (n = 115) and altered hours the least (n = 41).

Use of trial Med 3 date sections

Completion of sections (iv) and (v) was mandatory. GPs completed both sections in 68% of cases.

Completion time

Eighty-eight per cent (of trial Med 3 GPs) thought using the trial Med 3 rather than the current Med 3 would take longer in live consultations.

GP experiences of using the trial Med 3 form

GPs reported that the trial Med 3 is missing a clear time period for which the fitness for work assessment applies. GPs used sections (iv) and (v) inconsistently and ambiguously; some GPs thought it was irrelevant to ask when they would like to see the patient again. GPs expressed uncertainty about when and under what circumstances an employee was expected to return to work if assessed as ‘you may be fit for some work’, and how this relates to employers' willingness to follow the Med 3 advice. GPs thought the space for diagnoses was insufficient and wanted an ‘occupational health assessment’ box.

DISCUSSION

Summary of main findings

GPs using the trial Med 3 were less likely to advise cases to refrain from work, and provided more written fitness for work advice compared to GPs using the current Med 3. For both forms, GPs were more likely to consider the back pain case ‘fit for (some) work’ compared to other health conditions. Trial Med 3 GPs were more likely to utilise the new ‘fit for some work’ category, work solutions, and larger comments section for back pain cases. This may reflect GP awareness of the stronger evidence base for vocational rehabilitation interventions for people with back pain.19 The depression case was least likely to be considered fit for work, in line with other research.1618 The date sections of the form were used inconsistently and the period for which the assessment applied was often unclear.

Strengths and limitations of the study

The major strength of this study is that it enabled GP trial and current Med 3 responses to be compared, while holding all other factors constant. It offered over 3000 GPs the opportunity to contribute information about how Med 3s are used, and highlighted areas for form redesign to inform public consultation. However, there were some notable limitations. While the PCO response rate did not affect the intended spread of PCO characteristics, the low GP response rates mean that the findings may not be representative of all GPs within participating PCOs. Different assessments of fitness for work might be observed in another GP sample. However, since the GP demographics did not differ between current and trial Med 3 groups, it is expected that the observed differences between GPs would be repeated in another sample. The study compared the trial and current Med 3 in three patient scenarios, and alternative scenarios may have different results. The intention was to compare the trial Med 3 with usual practice; therefore, guidance was provided only to trial Med 3 GPs (current Med 3 guidance is already available).20 It is possible that the trial Med 3 guidance encouraged consideration of fitness for work issues. Inconsistencies in usage of trial Med 3 date sections made comparisons impossible.

Comparison with existing literature

GPs suggest that the Med 3 could be improved to indicate that the patient ‘could undertake some form of work, although not their usual occupation’, to provide ‘more specific details of prognosis of the condition in terms of the potential time of a return to work’ and more space for comments.11 The present study indicates that GPs used the trial Med 3 sections designed for comments and for return to work advice and were less likely to advise patients to refrain from work.

A number of studies indicate that patients with a mental health condition are less likely to be assessed fit for work compared to those with physical health conditions.1618,2124 This study also indicated that a patient with depression was more likely to be advised to refrain from work than a patient with back pain.

Implications for future research and clinical practice

The study findings informed the redesigned Med 3 introduced in the public consultation.12 The research indicates that a redesigned Med 3 could lead to fewer patients with back pain and/or depression being advised to refrain from work, and more written fitness for work advice being provided. This can facilitate discussions about return to work between employees, employers, and GPs, potentially aiding earlier return to work and reducing sickness absence, thereby benefiting patients, employers, and the economy. Future research will be required to monitor and evaluate the impact of the introduction of the final redesigned Med 3 form.

Acknowledgments

We thank the GPs and primary care organisations who participated in this trial. All participants took part voluntarily and no payments were made to GPs or primary care organisations. We thank Steve Bannister, Oliver Slocombe, Dr Nerys Williams, Katherine Hewitt, James O'Malley, Antony Billinghurst, David Carew, Dr Peter Wright, and Dr Suchita Nadkarni (all DWP) for their assistance at various stages of the project. We also thank the exert panel for their help in developing the vignettes, and the reviewers for their considered suggestions.

Notes

Funding body

The study was funded by the Department for Work and Pensions (DWP).

Ethics committee

The authors were advised by the National Research Ethics Committee that this study did not require ethical approval. The study was carried out to ethical and professional standards in accordance with the British Psychological Society code of ethics and conduct and with advice from DWP legal teams on Data Protection issues.

Competing interests

Anna Sallis and Richard Birkin are employed by the funding body — DWP. Fehmidah Munir is contracted by DWP to provide professional supervision to Anna Sallis. None of the authors were members of the stakeholder groups designing the trial medical statement or members of the DWP policy secretariat supporting the groups. The content of this paper was decided by the authors.

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