Guidance

Advising patients about work

Published 8 July 2013

Accommodating common health problems at work:

• health professionals, patients and employers working together,
• dispelling myths and overcoming obstacles

Work and Health

GPs are in a unique position to provide advice about work, which is an important part of clinical management. However, it can be a difficult part of the consultation, which may produce feelings of uncertainty and frustration, and leave both doctor and patient unsatisfied.

A recent review of work and health provides the scientific evidence^{[footnote 1]}, from which this leaflet develops a few basic concepts to underpin evidence-based advice. Whilst recognising the complexities of adapting that advice to the patient’s circumstances, the principles are straightforward and generic.

The goals are more effective communication, and improved clinical and vocational outcomes.

Work is good for health

Work is an integral part of life, which is central to individual identity, social roles and social status, as well as meeting financial and psychosocial needs.

For people with common health problems, there is strong evidence that work

• promotes recovery and aids rehabilitation
• leads to better health outcomes
• minimises the harmful physical, mental and social effects of long-term sickness absence
• improves quality of life and well-being
• reduces social exclusion and poverty

Key information to obtain and record

Employed/not employed? Job?

Off sick? How long?

On disability or incapacity benefits?

Sick certificates issued?

Unemployment is bad for health

There is strong evidence that long periods out of work can cause or contribute to:

• higher consultation, medication consumption and hospital admission rates
• 2 to 3 times increased risk of poor general health
• 2 to 3 times increased risk of mental health problems
• 20% excess mortality

The longer anyone is off work, the lower their chances of getting back to work.

These health risks are greater than many ‘killer diseases’ or some of the most dangerous jobs in the construction industry or the North Sea.

Overall, the beneficial effects of work outweigh the risks of work, and are greater than the harmful effects of being out of work.

Topic to discuss with patient

The health benefits of work

The ill effects of prolonged periods out of work

Fitness for work

This evidence has important implications for advice about work.

The long-term consequences of advising or agreeing that a patient should stay off work may be greater than those of the original health problem. The danger is drifting into long-term sickness. Prolonged sickness absence, long-term incapacity and ill-health retirement can have devastating effects on the lives of patients and their families.

This implies a duty to discuss with patients whether staying off work is the most appropriate management. Are there other (better) ways of managing the problem? What are the risks of sickness absence and do they outweigh the benefits? Many patients want to return to work as soon as possible, and most appreciate such discussions.

Topic to discuss with patient

Work as therapy and rehabilitation.

The risk of drifting into long-term sickness.

Common health problems

This leaflet focuses on common health problems - the mild/moderate conditions that make up the bulk of a GP’s workload:

• mental health
• musculoskeletal
• cardio-respiratory

Common health problems share a number of features:

• High prevalence across the working age population
• Many have little or no objective pathology or impairment
• Symptoms often recurrent, but most episodes settle rapidly
• Generally no obvious occupational cause
• Many people remain at work or return to work quite quickly

Most common health problems are manageable: most people cope with them most of the time, and most health care is effective. The paradox is that two-thirds of certified sickness absence, long-term incapacity and ill health retirement are due to common health problems. So why do some patients do not recover as expected?

Most of these patients do not have a more severe medical condition. Rather, something has gone wrong with the way things have been handled – by the patient, the health care system, or the workplace. So the answer is not more health care interventions, but a fundamental re-think about common health problems and their management.

Obstacles to recovery

Many obstacles can get in the way of normal recovery: identifying and overcoming obstacles is fundamental to good management.

Health-related obstacles:

• Ineffective treatments
• Inappropriate referrals
• Waiting lists for investigations or specialist appointments
• Unnecessary sick leave
• Unhelpful advice
• Failure to encourage and support return to work

Personal/psychological obstacles:

• Negative attitudes and beliefs about health and work
• Uncertainty about what is wrong, what to do, and the future
• Anxiety and depression

Occupational/social obstacles:

• Poor absence management
• Loss of contact with workplace
• Lack of modified duties
• Lack of support
• Breakdown of social and working relationships
• Litigation

Topic to discuss with patient

What is preventing you going back to work?

What could be done to overcome these obstacles?

How about modified duties?

Many obstacles arise from myths and misunderstandings. Patients come with their own beliefs and expectations about health and work, which may be unhelpful for their long-term health interests. Challenging misconceptions is one of the simplest and most effective ways of overcoming obstacles. Effective communication can dispel misunderstandings.

Common Myths	The scientific evidence
Common health problems: are usually caused by work	* They are usually idiopathic or multifactorial. Work is only one and usually not the most important causal factor.
mean underlying damage or disease	* There is often little or no underlying disease or permanent damage. Even when there is, incapacity is not inevitable
will be cured by medical treatment	* Treatment can provide symptomatic relief, but usually does not ‘cure’ common health problems.
are often made worse by work	* Work may be uncomfortable or difficult for a time, but work usually does not cause any lasting damage.
need sickness absence	* Most workers manage to remain at work or return to work fairly quickly, even though symptoms may persist or recur. * Long-term sickness absence is rarely necessary or helpful.
mean no possibility of return to work till 100% fit	* Work is therapeutic and an essential part of recovery * Patients usually should be encouraged and supported to return to work as early as possible, even with some symptoms.
You can’t lose your job if you have a medical certificate.	* Untrue! Some workers do get paid off if sickness absence is prolonged or frequent.

What the doctor says can be a powerful intervention – for good or harm. The wrong words, about the health problem or its relationship to work, can create or reinforce myths. Explanations should reflect the evidence. Choice of words is important –give positive messages and dispel the myths.

Topic to discuss with patient

Discussion about what patients can still do – rather than what they can’t

Return to work planning

With common health problems, clinical management is often about managing symptoms sufficient to allow the patient to maintain or return to normal activity levels. Recovery and return to work are active processes that involve the patient’s own motivation and effort. The doctor’s role is reassurance, support and facilitation.

Many patients find it helpful to have a return to work plan, and doctors can make an important contribution:

• Agree realistic goals and expectations of health care.
• Encourage incremental increase in activity levels
• Agree clear goals and timeline for return to work
• Discuss what patients can do rather than tell them what they can’t
• Discuss how to overcome any obstacles to return to work, and think about communication with the employer
• Talk about possible sources of support to help cope with the condition

Communication

Return to work depends on doctor, patient and employer working together. Everyone doing what is needed when it is needed – and avoiding anything that could impede the process. That depends on communication. Providing information and advice is as important as prescribing or certification.

Contact with any occupational health services (if available) may help to coordinate and facilitate return to work. Communication with employers should describe what tasks the patient can do, as well as any temporary restrictions that are medically essential. The Remarks section of the Med3 may be a convenient way to save writing a letter. The patient may provide the simplest channel of communication.

The doctor’s professional responsibility is to the patient, but the employer can be an ally. Patients’ long-term interests are usually best served by facilitating return to work. Respecting confidentiality is important but need not be a problem: most patients are glad to give consent once the benefits have been explained.

Key points:

1. Work is generally good for physical and mental health, therapeutic and an important part of rehabilitation

2. Long periods out of work are harmful for physical and mental health.

3. Two-thirds of sickness absence, long-term incapacity and ill-health retirement are due to mild/moderate ‘common health problems’. Much of this should be preventable.

4. Advice to stay off work is a major clinical intervention with potentially serious long-term consequences

5. Common health problems can often be accommodated at work, if necessary with appropriate adjustments and support.

6. Planning and supporting return to work are important parts of clinical management

Evidence Base and Resources

Is work good for your health and well-being? - an evidence review. The Stationery Office, London 2006

Concepts of rehabilitation for the management of common health problems. – an evidence review. The Stationery Office, London 2004

Workplace interventions for people with common mental health problems - an evidence review. British Occupational Health Research Foundation, London 2005.

The Health and Work Handbook – a partnership guide for primary care and occupational health teams : www.rcgp.org.uk

Occupational Health Competency Framework and Resources. Faculty of Occupational Medicine.

Resources for patients:

Health & Work – a self-help booklet for patients

Off work sick and worried about your job? – an HSE booklet for patients.

©TSO 2007

To order additional copies of this leaflet telephone 0870 600 5522 quoting ISBN 9780117037724 or go on-line to www.tsoshop.co.uk

1. Waddell G, Burton AK. Is work good for your health and well-being? The Stationery Office, 2006 ↩