Project objectives

The underlying hypothesis is that GPs trained to the level of the Diploma in Occupational Medicine of the Faculty of Occupational Medicine when compared to a randomly selected sample of GPs will have a more positive attitude towards the ‘fit-note’, will use the ‘adjustment needed’ provision of the form more often, and will differ also in the frequency of recognition of work-related ill health.

The study aims to determine whether GPs with prior training (to Diploma level) in Occupational Medicine differ from a randomly selected sample of GPs with respect to:

1. their attitudes to the new ‘fit-note’ and 
2. their behaviour in the recognition and management of cases of suspected work-related ill-health and associated sickness absence.

Brief summary

Background

Dame Carol Black’s 2008 report placed great emphasis on the role of the GP in helping their patients, as well as the economy, by giving appropriate advice in a new ‘fit-note’ implemented in 2010. Moreover GPs can also help their patients by recognising when ill-health is work-related. However the role of training of GPs in occupational medicine in respect of their attitude and capacity to giving advice on work adjustments in the new ‘fit-note’ was unknown. Additionally the presumption that GPs trained in occupational medicine would behave differently from a random sample of GPs in recognising and managing work-related ill-health (WRIH) had yet to be tested.

Objectives

The first objective of the study was to compare the attitudes and beliefs of GPs regarding work and health; the role of rehabilitation and especially theirs in respect of ‘fit-notes’. This was achieved through a cross-sectional postal questionnaire survey of GPs comparing those selected at random with a group of GPs having had prior training in occupational medicine. The second objective aimed to compare the actual practice of GPs in recognising WRIH and in managing the associated sickness absence. GPs selected at random were to be compared longitudinally over one year with the group of GPs having had prior training in occupational medicine via self-report data on individual, but anonymous, cases using a secure web based method.

Hypothesis and aims

The underlying hypothesis was that GPs trained to the level of the Diploma in Occupational Medicine of the Faculty of Occupational Medicine when compared to a randomly selected sample of GPs would have a more positive attitude towards the ‘fit-note’, would use the ‘adjustment needed’ provision of the form more often, and would differ also in the frequency of recognition of WRIH.

The study aimed to determine whether GPs with prior training (to Diploma level) in Occupational Medicine differ from a randomly selected sample of GPs  with respect to:

1. their attitudes to the ‘fit-note’ and 
2. their behaviour in the recognition and management of cases of suspected WRIH and associated sickness absence.

Methods

In respect of objective 1: the study design consisted of a cross-sectional questionnaire survey carried out with GPs selected to participate at random and compared with a group of GPs having had prior training in occupational medicine. The survey included nineteen questions relating to GPs’ views on work and health; their role, training and confidence in promoting the health benefits of work; early experience of fit notes; and the availability of services to support patients back to work.  Questions were organised into themes (relationship between work and health (2 questions); GPs role in helping return patients to work (3); return to work management (2); knowledge of certification system (3); impact of fit note (6); support service availability (2); training in work and health (1)) and GPs were asked to indicate their answer on a 4-point Likert type scale- completely disagree / somewhat disagree / somewhat agree / completely agree. For support service availability questions, an additional (fifth) option was added, i.e. a ‘don’t know’ response. The ‘training in work and health’ question was a simple yes / no response about whether the GP had received any training in health and work in the previous 12 months.
For objective 2: GPs selected at random were compared prospectively over one year with the group of GPs having had prior training in occupational medicine in respect of their recognition of WRIH and the advice that they provide on the ‘fit-notes’.

Key findings

Objective 1: Results indicated that responses from GPs who had undertaken training in occupational medicine (GPs reporting to The Health and Occupation Research network in General Practice (THOR-GPs)), and GPs having received some form of work and health training in the previous 12 months were generally associated with significantly more positive attitudes to return to work and to the fit note than GPs with no training. Associations persisted after controlling for age-group, gender and contract status.  Objective 2: GPs with training in OM may differ from other GPs in their management of patients with health and work problems, including the recognition of the effects of work on health.  This was to be assessed via collection of incident data for 1 year from GPs with no training in OM.  However, 1975 GPs presumed not to have OM training were selected and contacted; however only 15 agreed to participate and further research was therefore not pursued.  The key finding to draw from objective 2 is the difficulty in getting GPs to engage in research investigating worklessness / sickness certification and rehabilitation.

Impact and conclusions

The study reveals a noticeable difference between trained and non-trained GPs in their attitude to the fit note and work and health generally, and further work which could evaluate the effect of occupational medicine training on the recognition and management of ill-health should be undertaken.

Plain English summary

Work should not harm the health of workers, and when it does patients would expect their doctors to recognise this and do something about it. Generally speaking (‘good’) work is beneficial to health and doctors should do as much as possible for the sake of their patients as well as the economy to help their patients return to work. In 2010 the old ‘sick-note’ was replaced by a ‘fit-note’ that allowed doctors to make recommendations, such as a phased return, to help them get back to work. The applicants have already shown that GPs in general see themselves as playing an important role in promoting the health benefits of work, and ‘fit notes’ have helped them do so. The first objective of the study is to determine whether GPs with training in occupational medicine have different perceptions and attitudes regarding the ‘fit-note’ when compared to ‘average’ GPs. The applicants have already shown the extent to which GPs with training in occupational medicine can recognise work-related ill-health and use the fit-note to make recommendations to make work better suited to their patient. The second objective of the study is to determine whether these GPs with training in occupational medicine differ from ‘average’ GPs in recognising when ill-health has been caused or made worse by work and in their use of the ‘fit-note’ in such cases. If this study were to show that training in occupational medicine was associated with a favourable difference between the two groups of GPs, then a further study could be planned to evaluate the effect of occupational medicine training resources which already exist.

Dissemination

1. Annemarie Money, Mark Hann, Susan Turner, Louise Hussey and Raymond Agius. The influence of prior training on GPs’ attitudes to sickness absence certification post-fit note. Primary Health Care Research and Development, Cambridge University Press. January 2015.
   http://journals.cambridge.org/repo_A94hHYyo

Public involvement

GPs and policy customers in both the Department of Health (DH) and Department for Work and Pensions (DWP) were consulted extensively on the design and content of the survey questionnaires. Public release of information arising from the surveys has been done through DH, DWP and NPCRDC reports.

In order to make the results and implications better known and discussed amongst physicians with a special interest in occupational medicine, the findings will be disseminated to and debated with doctors in The Health and Occupation Research Network (THOR). THOR currently includes over 1000 reporting physicians (General practitioners, occupational physicians, consultant dermatologists, consultants in communicable disease and chest physicians):

http://www.population-health.manchester.ac.uk/epidemiology/COEH/research/thor/

The Centre for Occupational and Environmental Health (COEH) which runs the THOR network is part of the Centre for Epidemiology of the Institute of Population Health of the University of Manchester.  The COEH already holds 3-4 meetings per year with doctors who report to THOR and including workers’ / patients’ representation (usually from a senior Trade Union member) to appraise them on, and discuss with them the ongoing research on work-related ill-health and sickness absence. The OPRA/THOR meeting of 19th June will feature the results and discussion of this project on the agenda. 

Furthermore, physicians participating in THOR receive a report each quarter, an overview of the project and its results will be included as a feature in the June 2014 quarterly report.

After peer reviewed publication, (and with the agreement of the journal editor) a lay summary of the project with a link to the paper will be added to the website.

Besides the peer-reviewed publications, it is proposed to continue to use the website for public dissemination of the findings as exemplified by our current practice:  http://www.coeh.man.ac.uk/demo

Impact

The main implication of this piece of work is in its potential to inform the development of clinical practice in primary care, since it clearly concludes that training of GPs in occupational medicine / work and health, is associated with a more favourable attitude to the fit note and ‘return to work’ issues. Since the study design was cross-sectional rather than a more expensive and time consuming longitudinal design with controlled intervention we cannot necessarily conclude that the association between training in OM and positive attitudes towards workplace rehabilitation is definitely causal. Nevertheless there is enough substantial evidence to justify a longitudinal study and to encourage further training in OM for GPs with the aim of improving patients’ health and well-being at work as well as having a positive economic impact.

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 138)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.