Fit for purpose

Work is good for you. Numerous research projects point the same way: staying at home longer than you need actually makes you worse. Of course, your absence also costs your company and overloads your colleagues, so getting you back in the shortest possible time is in everyone's best interests. It's therefore surprising that so few companies have apparently homed in on this. Ask manufacturing managers what they do about absenteeism and they reel off a long list. But ask them about their strategy for rehabilitating people after an injury or illness and their faces go blank, even though the fit note was introduced last year specifically to emphasise and ease this process. The fit note allows doctors to suggest work still within a patient's capability instead of simply signing them off. Good idea, you'd think? Yet, according to the EEF/Westfield 2011 sickness absence survey, only 17% of companies have actually made adjustments to allow employees to return more quickly. Could this unwillingness have anything to do with the apparent demise of the in-house occupational health (OH) department? It's difficult to arrive at firm numbers but only the largest companies seem to have them today. Sue Barrigan, occupational health adviser at ConvaTec UK, was stunned to hear herself described as "one of a dying breed" at a recent OH conference. As manufacturing companies get smaller and the mantra of 'core competence' dominates, the emphasis has shifted to buying in external OH services, insuring or paying for private treatment for key staff, or simply doing without. What, if anything, is industry losing if external providers replace in-house OH? Let's take a look at what each type brings to the organisation. Firstly, the traditional approach from medical device manufacturer ConvaTec UK which employs just short of 1,000 people. Sue Barrigan and a part-time assistant look after two factories in Wales plus a more scattered commercial organisation. She also has the services of a physiotherapist for six hours a week and an OH physician on an ad hoc basis. As well as conducting statutory health surveillance and fitness-for-duty examinations, Barrigan – a qualified OH nurse – acts as first-line support for supervisors and managers in absence management and return-to-work programmes. Any absence triggers a return-to-work interview, conducted by a supervisor or immediate line manager. If the employee has been off for more than 12 days or has shown a high frequency of short-term absences over a year, they are referred to the OH department. Barrigan emphasises this is not punitive: "We have a duty to care for them – four similar absences mean something is a problem for them as well as the company and we need to look at whether they are getting the right advice." Feedback to the manager never includes medical details, but Barrington will ask for adjustments to their work, indicate what attendance is likely to be in the future and when an improvement could be expected. Employees must be referred to OH by their managers via a standard form completed in consultation and with their consent. So when they come to Barrigan, there is no doubt why they are there. OH has been pushing hard to get people referred before major treatment, with tangible advantages for all concerned. It lets the team look at their functional capability and support them back to work through an individual plan. For someone recovering, say, from a heart operation, Barrigan may specify reduced working hours in a less demanding role with no tight deadlines. "This way, we can build a rapport with our employees, starting to put the idea of a return into their heads before they even leave the building. Twelve weeks is a long time to be out of contact with the workplace so I try to keep regular contact with them, as do their managers." When you do bring them back, you have to make sure you do it safely, she continues. "We will monitor them all the way through and revise the plan if necessary until they are back to full health." She can directly provide physio. In addition, most of the employees have private medical insurance so she can make direct referrals for treatment or surgery even if the problem is not work-related. She also encourages people to take advantage of ConvaTec's employee assistance programme (EAP) which gives them direct access to a range of specialists for confidential counselling and advice over the phone. Although EAP uptake is traditionally low everywhere, Barrigan believes it has an important role in rehabilitation which is often hampered by non-medical issues like financial worries. Overall, Barrigan says her aim is best practice, not rocket science. Managed services Now the view from the other side. FirstCare provides OH to clients in all sectors, usually in combination with outsourced absence management services. Commercial director Jason Taylor says the start point for both is ensuring absence levels are recorded accurately and that everyone is treated fairly. "By capturing the absence the minute it happens, it becomes a case which is managed by us through to the OH providers. It significantly reduces delays and we make sure they have access to everything available to them." It is mandatory for absentees to call FirstCare, although it is branded as their own company. Non-medical absences are recorded 24x7 by the call agent and emailed to the line manager. "They still conduct return-to-work interviews but populated with the information they need to know," explains Taylor. Medical absences are transferred to nursing staff who use triage scripts to understand more about what's contributing to the absence. "Where it requires a more in-depth OH piece, we'll get the manager involved," explains Claire Herne, head of health services. "He or she must ask the employee to agree to an OH referral which gives us the right to report back to the manager to manage their return to work." Unlike ConvaTec, much of the ensuing process takes place over the phone including the first consultation. "We are basically problem solving," says Herne. "From that call, we agree a case management plan." With the right budget, FirstCare can co-ordinate everything that is needed, including a face-to-face assessment, an appointment with an OH physician or physiotherapy, reflecting the results in the plan. She admits, however, that such funding is rare in manufacturing. "But this process is about empowering the employee so we will say 'you need X,Y or Z' – giving them the information to speak to their GP. We have to be very careful about trying to direct a GP's treatment pathway." OH is not necessarily out of the reach of SMEs. It is still possible to scale-down a referral system like ConvaTec's using a part-time OH professional. And outsourced services can be tailored for fewer employees and limited spends. Even so, smaller companies are still mainly dependent on NHS-based OH support. Which brings us back to the vexed issue of fit notes. According to Professor Sayeed Khan, chief medical adviser of EEF and a specialist in occupational medicine: "The reality is that the fit note makes no difference to those with good OH. The OH professional decides what an employee can and can't do. The fit note is for organisations that have to make do without." There is no doubt that the new system has taken a lot of stick recently. There have been widespread complaints that it has not led to better advice from GPs alongside pungent comments on the illegibility of the guidance they do provide. Khan – a prime mover in their introduction – admits many GPs aren't yet engaged but is adamant the situation is improving. A recent training programme by the Royal College of General Practitioners (RCGP) produced a marked shift in attitude, although it only involved 3,000 of the UK's 45,000 GPs. An electronic version of the fit note is now on the horizon, which Khan believes will force GPs to complete them fully and usefully. "Partly it's about training but part is about change – the biggest since the inception of the NHS. So it's going to take five years to embed. Then people will wonder what the old system was like." He maintains the fit note is not complicated: "If a GP says 'no heavy work or lifting' and the employer can't provide work of that type, the employee stays off." Khan still runs a clinic and sees what's on the ground. "The NHS waiting list is a massive problem. This isn't about getting sick people to work – it's about people waiting for treatment who could sit down and work but not stand, and post-treatment in the recovery period. We need a culture of gradual rehabilitation to help people get into work." Factory visits RCGP recently ran pilots to bring GPs into local factories. "It means they know just what kind of work happens there and what can be offered over the rehabilitation process," explains Khan. "It works in both the GPs' and the employers' interests." Nearly 30 GPs turned up to one such tour at BMW in Cowley. Now Khan is looking for more manufacturers to offer small-scale sponsorship for similar events in their own factories. Contact him on skhan@eef.org.uk. Obviously, GPs are more interested in touring larger factories employing many of their patients. But Khan says all businesses benefit by acting more proactively with local practices. "Our data shows that those who contacted GPs about the type of work they can offer had far more notes with 'may be fit for work'. He suggests writing to the practice manager: "It's worth saying that, if necessary, the company will pay for some treatment. GPs often aren't aware that SMEs may have some form of health cover. If someone needs physio, waiting six weeks for the NHS to kick in is a waste of everyone's time. £25 for a physio appointment against £500 per week off sick is a no-brainer." It can also be worth recommending an employee with a fit note to ask the GP if anything would speed up recovery or the appointment. "Everyone wants the same thing but there isn't a culture of talking to each other. Part of the purpose of the fit note was to start some kind of dialogue going. It's not going to work every time but it will work with greater numbers than ever before." Khan says too many employers believe they can't do anything about employees with chronic sickness: "Well they can. They'd get a bit of plant serviced and repaired – why should an employee get lesser treatment?"