Shared learning database

Leicestershire Fit for Work service (LFFWS)
Published date:
February 2011

One of 10 national Fit for Work service pilots across the UK aimed at providing early interventions to people at risk of long term sickness absence. The Leicestershire pilot is the only one led by a GP and has focussed entirely on receiving referrals from primary care and is unique in taking on responsibility for signing fit notes for the duration of service. The service is provided by a multi-disciplinary team that identifies barriers to work as soon as possible and provides or co-ordinates interventions towards a return to work in keeping with the guidelines in PH19 - Managing long-term sickness absence and incapacity for work

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Our vision is to: 1. Move management of sickness absence from the medical model into vocational rehabilitation. 2. Move vocational rehabilitation closer to mainstream primary care. This is based on our belief that this approach will identify barriers and provide access to interventions at an early stage to people who would otherwise not benefit from the approach outlined in PH19. Only 1/8 workers have access to occupational health services in the UK. Specifically our aims are to: A) Support the employed population of Leicester City and Leicestershire to get back to work more quickly when they are signed off sick by their GP or when they have been identified as being at risk of long term sickness absence. B) Develop a culture of support for primary care to better manage sickness absence and therefore reduce the morbidity, mortality and increased health seeking behaviour that accompanies long term worklessness. Provide a service that GPs can and will access easily when signing fit notes for problems that could be categorised as long term sickness absence or at risk of such absence. Develop a case managed service by putting together a multidisciplinary 'core team' of non-clinical case managers, with good interpersonal and communication skills, supported by an occupational health nurse and a part time GP. One-to-one consultation to identify specific barriers to a return to work within a week of referral and agree an action plan with the worker and their employer to overcome these barriers. This team to work together in to provide co-ordinated assessment with one to one flexible and personalised support. Develop or set up a working relationship with a network of support services such as musculoskeletal therapies, psychological therapy, debt / legal / housing advice, drug and alcohol support. De-medicalise the client journey where necessary and target interventions at the 'human issues' that underlie so many episodes of sickness absence. Access appropriate interventions quickly to reduce the risk of long term absence and monitor progress throughout these interventions. Support the absent worker until a return to work or an alternative outcome is clear and aim for this outcome to be a return to work for 75% of referrals. Monitor progress 1 and 3 months after leaving the service. Improve knowledge in primary care around the management of sickness absence by communicating with GPs about each referral. Specifically outline the barriers and interventions that made the return to work possible or outline the reasons where intervention was unsuccessful. Achieve commitment from Leicester City and Leicestershire County GP's to refer into the service and to allow us to take responsibility to sign and manage their patients 'Fit notes'. Measure the cost per case as part of the overall evaluation.

Reasons for implementing your project

'The medical sickness certificate is one of the most powerful and potentially dangerous treatments in the GP armamentarium'. These are the words of Professor Waddell when introducing the evidence review, Is Work Good for Your Health and Well-being' This conclusion reflects the growing consensus that any national approach to reducing sickness absence levels needs to engage with mainstream primary care. Vocational Rehabilitation: What Works, for Whom, and When is a systematic review of 450 scientific reviews and reports. The findings support the principle of a co-ordinated return to work plan, the importance of identifying people at risk of long term sickness absence from primary care and de-medicalising the reasons for absence. The split between mainstream primary care and vocational rehabilitation was well recognised in Leicestershire but had never been addressed in a systematic way. Local dialogue revealed that most GPs agreed that their usual referral pathways in the health sector did not address all the problems keeping people off work as they signed fit notes. However in Leicestershire, there were many services that could help the absent worker. The people running these services reported difficulty engaging with GPs. Primary care and vocational rehabilitation were operating in completely different worlds! Our conclusion was that a local pilot could brings these worlds closer together and that a formal bid to become one of the ten national Fit for Work service pilots would be an ideal way forward. Analysis of local Joint Strategic Needs Assessments revealed that while the number of people moving off Incapacity Benefits was increasing, the flow of people onto such benefits was also increasing, particularly for mental health disorders. PH19 provides £900 per case as the cost of managing absence that would show value for money to an employer or society at large. This target figure provided us with a measure of economic benefit.

How did you implement the project

Our project is one of 10 national Fit for Work service pilots, part funded by the DWP. By using a LFFW Service GP to sign our clients' fit notes; we are able to have greater control over the client journey. This removes the potential for the clients' fit notes to be in conflict with the return to work action plan developed by the service. The service organises phased returns, work adaptations or in-work support that the clients' own GP cannot facilitate. Our approach of taking responsibility for sickness certification away from GPs facilitates early intervention and is welcomed by most GPs. Endorsement by local GPs. Engagement with Primary Care can often take considerable time and effort to achieve the LFFWS used its ability to sign fit notes in our service to engage GPs and develop a strong relationship. All 160 City and County GPs signed up to a commitment to refer clients into the service. In designing this service we felt it necessary to provide individualised support via an extensive network of services already funded by government or the voluntary sector. This allowed clients receive support from local providers with local knowledge, delivered in a location close to where they live. Frequently, resolving practical issues can address the cause of stress related symptoms. Continue to support clients after their return to work. We decided maintain contact with clients at one, three and six month intervals to offer additional support if required to sustain the client in work. Our evidence suggests that continuing contact with the client may prevent future sickness absence. Employer engagement and mediation. The service develops skills in mediation which has been critical to maintaining employer/employee relations and supporting sustained work. We use mediation where a breakdown in relationship between employer and employee or where illness or injury requires adaptations of adjustments to the work environment, duties or hours.

Key findings

The service has received more than 400 clients since the pilot began in April 2010 and assisted nearly 200 clients through the links we have created with county GPs. We have successfully returned 69% back to work, our biggest success has been returning clients with mental health issues to work - here we have a 92% success rate. As one of 10 national Fit for Work Pilots, we are part of a national evaluation process. (The word document -LFFWS Supporting documentation NICE shared care awards February 2011 provides more detailed demographics of the intervention population.) 89 clients have been discharged from the Fit for Work Service (as at 1st February 2011). Returned to work after sickness 60% Supported to remain in work (no sickness)13% Became unemployed 10% Refused return to work action plan 18% Clients often receive more than one intervention. We asked which intervention made the most impact to their particular case. Musculoskeletal therapy 20% Mental health therapy 20% Mediation / Negotiation with Employer 20% Learning & Skills advice 15% Debt / Legal / Housing advice 15% Advice on finding new employment 10% The success of the pilot has meant that we have been requested to present at the following: - Health and Wellbeing at Work Conference - March 2010 - GP Trainers conference - September 2010 - RCGP Annual Conference - October 2010 - Health, Work and Well-Being Conference October 2010 - East Midlands Improving Access to Psychological Therapies conference - November 2010 - Cross Government Workshop on Health, Work and Wellbeing-Next five years strategy development - December 2010 The pilot has also attracted interest at a national and ministerial level, including: - Visit from Lord David Freud (Parliamentary Under Secretary of State, Minister for Welfare Reform) and Dame Carol Black (National Director for Health and Work) - September 2010 - BBC Radio 4 PM programme 28th January 2011.

Key learning points

Emphasise impartiality of your service at every available opportunity. This develops the trust that can highlight the 'human problems' that account for more than 50% of cases where fit notes are being written for medical or psychological diagnoses. Problematic relationships and false perceptions are the most commonly encountered human problems that end up being medicalised in fit notes. The LFFWS core team has received formal training in mediation. The skills developed have been vital to the success of many of our interventions. Reframing and encouraging the absent worker to reflect on the perceptions of others has been successful in starting the process of resolution. LFFWS has successfully returned 92% of our clients with a mental health diagnosis to work. > 50% had practical solutions to their problems. Therapy is often unnecessary. Employment support services should consider practical solutions before considering therapy. If psychological therapy is required, the needs and outcomes need to be specified to the therapist and client. NHS practice based therapies are rarely targeted to specific needs. This is a particular problem when helping people with fibromyalgia (FMS), chronic fatigue syndrome (CFS)or thought rigidity. Neuropathic pain (NeP) is under diagnosed by GPs, occupational physicians and specialists. Always consider NeP where pain causes absence for more than 4 weeks. We have made a new diagnosis of neuropathic pain for many clients that, when treated to the guidelines in NICE CG96 - NeP, have improved and returned to work. People with FMS or CFS account for a large proportion of people at risk of long term absence. Our success in early intervention have been encouraging. However we have found that long term absence is a particualr problem with these diagnoses. We would advise that a long consultation with a doctor ASAP to recognise the validity of symptoms is vital to successfully introduce the appropriate advice from 'CG53 - CFS'.

Contact details

Dr Robert H Hampton
General Practitioner and Clinical Lead for the
Leicestershire Fit for Work service (LFFWS)

Primary care
Is the example industry-sponsored in any way?