e17 Fit note challenges

PLEASE NOTE: This transcript was produced largely using AI and may contain errors.

 [00:00:06] Munir Adam: Hi guys. Welcome back to primary care UK. It's Munir Adam here, and this is the second half of the discussion around fit notes. The first half, as you remember, was an interesting discussion covering the basics, and... 

[00:00:18] Marium Hanif: Really you found it interesting. I thought you found it boring Munir. 

[00:00:23] Munir Adam: Well, it wasn't too bad, I suppose.

[00:00:24] Marium Hanif: Okay. Sorry folks didn't introduce myself. So my name is Marium Hanif and I'm a PA. So from my perspective, I definitely found it interesting, the last episode, and it was helpful and actually it prepared me for what we're going to cover today, and it is an interesting topic today, we'll all be talking about, well Sarah and Saira will be talking about the challenges clinicians might face when dealing with fit notes. 

[00:00:49] Munir Adam: Yeah, that's right. And a bit about important things to bear in mind. 

[00:00:52] Marium Hanif: So as we did last time, let's turn again to Nottinghamshire Alliance training hub and listen to Sarah and, Saira's talk today.

[00:01:14] Saira Jawaid: Hello all. I'm Saira a GP in Nottingham. I met you all last month with the first episode of Basics of Fit notes podcast. Um, welcome to our follow up podcast Today. Sarah was tasked to do some learning.

[00:01:29] Sarah Partridge: Hi, my name is Sarah Partridge and I'm a clinical pharmacist in Nottingham. And you're right. Last month when we met, I was sent away to complete some e-learning training, health package on fit notes. So we're back.

[00:01:43] Saira Jawaid: Yeah. How did that go?

[00:01:45] Sarah Partridge: Do you know what? I found it. It was, you think from the outside it's a bit of a boring, dry topic.

However, do you know what? It was quite interesting. And I realized, looking back, I've probably underestimated the process and it's not really a tick box exercise that I originally thought. It's about empowering and working with patients and I was really, really shocked. By some of the statistics that they gave in the package.

For example, 15% of patients that have been off work for four weeks with a kind of musculoskeletal condition, um, they never return to work, which is quite shocking.

[00:02:21] Saira Jawaid: Yeah, so that's an interesting fact and it just shows us how important it is to think of the length of time signed off for patients, and we should encourage them to go back to work as early as possible.

[00:02:33] Sarah Partridge: Yeah, so that definitely became clear and I suppose that's why they changed their names to fit notes. It was trying to work with them to find out what they could do, not automatically let them be at home necessarily. Cause that, of course, that has enough on effect on mental health and their physical health.

So actually there's a lot of benefits of working. But I did have a few questions. 

[00:02:55] Saira Jawaid: Yeah of course.

Consequence of time off

[00:02:57] Sarah Partridge: So I'm thinking more from like a practical perspective. If I was to do some fit notes,

What relevant questions can we ask the patient to help explore their occupation and think about adaptions and what they can do?

[00:03:11] Saira Jawaid: Yeah. So you need to explore and ask questions that would help your assessment. So some of the examples are, how does their medical condition impact on their work? For example, what difficulties they might be having incurring their own tasks because of this medical conditions. Are there any requirements of their job. Is a desk based, for example, or is there physical strenuous work, but also to consider safety aspects such as driving and operating machinery. So you're gonna ask all these questions and find out a bit more about their occupation.

[00:03:46] Sarah Partridge: So just find out a bit more. But yeah, it's really important actually you raising the fact about driving heavy machinery because if they were on any medication that kind of made them feel sleepy or something like that, that would be really important to bear in mind. 

And what you kinda have all the information you think you need to make kind of some recommendations, have you got any really good hints and tips?

[00:04:09] Saira Jawaid: I think the most important thing I would say to remember is making sure that information that you provide is factual and avoid any speculations. You know, you need to be careful and need to be confident and safe and, and sort of provide the objective evidence and the facts rather than your judgment on the condition.

[00:04:31] Sarah Partridge: Okay, so if for example, you kind of had a vague idea, but you thought occupational health might be the better place to kind of make an assessment, could that be one of the recommendations?

[00:04:42] Saira Jawaid: Yes, certainly patients can be referred to occupational health by their employer. If an employer wants more information or if you feel out of your depth in making an assessment, um, you can write in the comments section that a referral to occupational health is recommended. It will be an employer's role to do so. But the patients can request the employer to have an occupational health assessment if that's what they wish so.

[00:05:08] Sarah Partridge: Brilliant. 

The other thing I thought was, what do you do if a patient has a specific request in mind? So what I'm thinking is that they say that they could only work till 3:00 PM as this works better for school collection. Are we able to do that?

[00:05:24] Saira Jawaid: So that's a very good question. Because patients may ask you to state specific requests. Say for example, they may say, I want to work x number of hours on this day. But I would say anything that is difficult for you to defend medical legally should not be done if it is not related to their medical condition.

So you need to communicate that with the patient that this isn't something you can provide because it isn't to do with your medical condition.

[00:05:52] Sarah Partridge: Brilliant to stick to the facts .

[00:05:54] Saira Jawaid: Yeah. So how, how is impacting their um, work. But you can't ask for, for other conditions like you mentioned for school collection, childcare, or, you know, just for convenience, I guess. . We are not gonna be able to do that.

Long-standing absence from work

[00:06:08] Sarah Partridge: Another area I thought could be quite challenging was those related to long-standing fit notes. Because you see in general practice patients that recurrently get fit notes and are the ones that I've seen are treated a bit like a tick box exercise. So how, how do you challenge one of those longstanding fit notes when you think they, they could work potentially?

[00:06:32] Saira Jawaid: Yeah, so that's where I think a really good rapport with patients comes into play and empathy towards them and communicating that being off work is not always good for them. Longer, they're off harder it is for them to get back into it, like you mentioned in your statistics as well. So having a routine and keeping busy. That will help their mental and physical health. 

Um, and one thing I would highlight is it's okay to say no to issuing a fit note. Don't be coerced into doing one. If patients don't agree with you, they can have a second opinion from another professional if needed. But just because they've been off for a long time doesn't mean you can't challenge the situation, and again you'll be responsible for the fit note that you're doing. And therefore it's important to be comfortable and confident with it and, and encourage them to go back to work. And whether there are adjustments or other help and support you can provide to them. It's still really, um, you know, important to challenge it.

[00:07:31] Sarah Partridge: Brilliant. So, and I suppose this where the benefit of maybe working within the multidisciplinary team, so where there might be a few more challenges, having that confidence of being able to go to your colleagues and say, oh, can we just discuss this one? I feel they may be able to go back to work, what do you think, I suppose could be beneficial?

[00:07:51] Saira Jawaid: Yeah, so it's whether it's like a physiotherapist or occupational therapist or a mental health nurses, et cetera, I think it is a very good point that in involving other members of the team and getting an idea from them, how well you can assist these long-term patients to go back to work is really important.

[00:08:08] Sarah Partridge: Brilliant. 

Requests from other specialists

[00:08:09] Sarah Partridge: Another area, what should you do if like the hospital trust or someone asks you to write a fit note, because surely they should be doing it.

[00:08:18] Saira Jawaid: Yeah, so other organizations may ask you to issue a fit note for the patients. As per BMA guidelines, British Medical Association, um, that's not strictly your job to do it. Um, and all professionals have a duty to do these themselves. 

However, if you do oblige, I would say only do them if you feel confident about it. A request for instance, from a consultant to get a fit note from your GP doesn't protect us. We have to make our own judgment of each situation. I mean, sometimes if a patient has come to see you and, and you've got enough evidence from the hospital such as out of hours attendance or emergency attendance, and they may have said or go and get it from your GP, you have to reassess the situation to see how they're feeling now.

Same with any surgery, um, post-surgery, or any examples where they may have said, oh, go back to your GP. It is your duty to assess the situation. 

 So ideally, like you said, they should be doing it. They are responsible strictly you, you not responsible GP practices or primary care is not responsible. However, if you know, if it is some something that you have to do, then yes, do you reassess the situation?

[00:09:27] Sarah Partridge: And I know in Nottingham, actually, they're working on this with the hospital trust at the moment, that they give a fit note for the duration, the normal standard duration that you would expect for say, surgical operations and procedures. So hopefully that will improve a little bit and that we should see...

[00:09:42] Saira Jawaid: Yeah. Yeah, that's a really good idea because I think trusts you'd realize that, you know, it's an extra work, I suppose, for the GP practices, but also the fact that we might not be the right people to assess.

Benefit system

[00:09:54] Sarah Partridge: Change of direction now, but it was a really confusing, muddy area in my mind. Can I clarify how fit notes linked to benefits?

[00:10:04] Saira Jawaid: Yeah. Okay. So that's good. Majority of the fit notes are used for statutory sick pay or occupational sick pay. However unemployed patients can apply apply for e ESA, which is the employment and Support Allowance, or for universal credit. But not for statutory sick pay. So the fit note be passed onto the job center by the patients and it'll either have a box that you've ticked not fit for work, or they may be fit for work boxes that are still relevant.

So do, do you still fill those in because it'll help the job center define the appropriate and the relevant jobs for the patients that are unemployed. The difference comes when people are self employed. Um, but say they're an employee of their own company, such as their director, or they have a limited company, they are eligible for statutory sick pay. But if you're a sole trader, then you're not. 

But if patients in general, um, if they're not able to apply for work, they can apply for e ESA or universal credit. So anything more detailed than that, needs signed posting to the job center, citizen advice bureau, or welfare rights.

[00:11:12] Sarah Partridge: Brilliant. So it, it's worth bearing in mind that sometimes fit notes can support and are used by the job center in support of certain benefits and things. Great. 

Bereavement

[00:11:23] Sarah Partridge: And then coming towards the end of my questions, you're doing a great job here. How do you deal with a fit note request post bereavement, because they might not actually have a medical condition.

[00:11:35] Saira Jawaid: Okay, so that area can be a bit difficult to judge. But the way to consider is that patient may have an existing mental health condition or a new mental health condition may develop due to the bereavement. For example, if it's a close relationship or an unexpected death has resulted, may result in a shock or anxiety and depression. So in these situations, you can issue a note. 

However, if it's not exacerbation of their existing mental health condition, or it isn't a new mental health condition, then you can't issue a note. So employers can grant a compassionate leave at their discretion. So I think in that situation, you have to be empathetic to patients and ask them to speak to their employers.

[00:12:20] Sarah Partridge: Okay, so it's a bit on a case by case basis and whether it's having a negative effect or creating a new mental health condition. Okay, so I think I've got my head around that a little bit more. So yeah, I'd probably be one that I'd go to my supervisor with. So thank you so much for all those answers. I think things are starting to be clearer in my mind.

[00:12:41] Saira Jawaid: No problem at all. I'm glad you're finding it helpful.

Example: Back pain

[00:12:44] Sarah Partridge: I also thought it'd be really good for myself and hopefully listeners of this podcast, if you could give us a real life example of a fit note situation, so that I can see and think about how to apply all this knowledge practically.

[00:12:58] Saira Jawaid: Yeah, sure. So I think a common... let's take an example of back pain because it is a common presentation in general practice. So as mentioned in the previous podcast, and, and in this previously, you will have to start the assessment. That's the most important thing when any presentation comes. So, for example, back pain in this case, you, you take the history, you do the examination, and then asking about the impact of back pain on their ability to work. What does their job involve? Are they sitting down? Are they lifting heavy weights or manual handling? Or does it involve shift work? Those are the things to assess. And asking what do patients think they can manage to do at work? 

And does that meet your expectation of how you would think that , that would be appropriate for somebody with back pain. So always important thing I would say is once you've made your assessment you can then, um, either , you know, feel that, okay, this, this is a time I can sign them off for, and say not fit for work. But important thing is always consider adjustments and focus on what they can do.

That is why, as we mentioned previously, is the purpose of the fit note is focusing on what they can do. And again, remember your other members of your team, like physiotherapist in this case, or occupational health therapist, um, or occupational health at work. Maybe you would want to also review the previous time off work, and that experiences, they matter as well. Has the patient been back, Has this patient been back for to work post a previous back pain, um, time off? How did it go? What things were considered in that case. And depending on the situation, I guess, like I said, you would give us your time off work, and reassess. Just be mindful again, not to, uh, do it longer than it's necessary because reassessment of the condition on regular occasion will engage the patients more and it will be beneficial for them to, to help support them.

And then tick box any if you're saying that maybe fit for work then, uh, tick, tick the adjustments or amended hours, et cetera. And that's where the comments box will be really helpful for the employer. Does that make sense? Uh, have you got any questions about that, Sarah?

[00:15:18] Sarah Partridge: Yeah, so it's a question of kind of working with the patient, hopefully reviewing regularly, and I suppose managing the patient's expectations so you're not gonna be signed off for a long time because actually it may be worth considering what you can do, and reviewing and looking at reducing hours or making a desk job or something, if that's still possible, depending on the pain and depending on the role and and things like that.

[00:15:44] Saira Jawaid: Yes. It's thinking broadly. Back pain, for instance, is a common condition, but you know, again, the evidence is that the quicker you go back to work and the more and more well you are, there are more benefits than staying off with these conditions for long time.

[00:15:58] Sarah Partridge: That's really good to hear. Saira for that.

[00:16:01] Saira Jawaid: That's okay. No problem at all. I think they were all very useful questions that you came up with.

Summary

[00:16:06] Saira Jawaid: Generally, how are you feeling about the fit notes as a whole now?

[00:16:09] Sarah Partridge: Well, I'm, I'm a lot more clearer, particularly around benefits and kind of the special cases with regards to bereavement or patient requests. Um, kind of what information you need when making that kind of assessment. And I really now appreciate that you need to understand the patient's condition. You need to be making shared decisions, working with the patient, finding out about their ideas, concerns, and expectations.

And ideally, what it sounds like to me is that patients need that time and that regular contact with the same clinician when renewing fit notes and things like that, working out what they can do. Cause actually long term, this is a much better idea. 

With regards to me personally, I need to make, I need to come across appropriate cases within my respiratory clinic. Cause that's the area where I'm familiar with the conditions and things like that. So kind of within my competence and when I come across certain cases, I'm not at the stage to go away and do it on my own at the moment. But I now have the information that under supervision from my GP that I'll be able to work on this and slowly build up my competence in the area.

So thank you so much for your support during this journey.

[00:17:24] Saira Jawaid: My pleasure.

[00:17:28] Marium Hanif: Wow. What an interesting talk today, eh? So what did you think Munir? 

[00:17:33] Munir Adam: Um, I'm now wondering if I should have actually shared this episode. 

[00:17:38] Marium Hanif: Why, I mean, last time you're doubting yourself and now you're not sure about this one. Why is that? 

[00:17:44] Munir Adam: Well, if finding about all the challenges is gonna put people off, We GPs are gonna be stuck with it for longer, right?

[00:17:50] Marium Hanif: Mm. No, I don't feel that way. In fact, I feel more motivated and Saira and Sarah didn't just share the challenges, but actually provided solutions as well. And I think it's really helpful for us healthcare professionals, PAs, pharmacists, and nurses. Furthermore, it may help you and other GPs, even like trainee GPs, would find this episode really helpful.

[00:18:12] Munir Adam: Yeah, no, I'm just kidding. Actually, this was a really important reminder for us cuz it's all too easy to slip into bad habits, even if we're familiar with fit notes in the first place. 

[00:18:21] Marium Hanif: Well, I hope the audience found this episode useful. We are grateful once again to Sarah Saira and maybe we'll hear from them again in the future.

[00:18:29] Munir Adam: But that's it for now. Do rate us an Apple podcast or in other ways. And do spread the word.

[00:18:34] Marium Hanif: And until next time, keep well and keep safe.

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