Going back to work after invasive cancer surgery is never going to be easy. For Graham Smith (not his real name), it was helped enormously by having a sympathetic line manager. When Smith asked to start back at his public-sector finance job on shorter hours after six weeks, it was no problem. When he had to take another week off because an infection developed, no one moaned. If he had needed extra time off, there was a contingency plan in place.

However, throughout Smith’s fluctuating fortunes in the wake of a prostatectomy, he had to negotiate directly with his manager, who had to trust him. When he felt fit enough to try a phased return, the GP had no choice but to declare him fit for work.

He believes a different manager could have put pressure on him to resume full hours sooner – or told him to stay away until he was fully fit. Smith would have welcomed the new “fit note” to be launched in April, replacing the current sick note provided by GPs. Under new government regulations, GPs will be required to state whether someone is fit for some work or unable to work at all.

If the GP decides the person is fit for some work, the form provides tick boxes for either a phased return to work, altered hours, amended duties or workplace adaptations. There is a large space for the GP’s comments, including a more detailed explanation of the effect of the patient’s condition on their ability to perform functions. This information could be included on the old forms, but now the layout encourages it.

Smith believes that the new form will help people to negotiate with their employers: “I would have welcomed the fit note under most circumstances, because it’s very difficult to negotiate with managers unless you get one like mine. The new note provides evidence about your condition, and what you are able to do, from someone independent.”

It was to encourage a speedier return to work that the fit note was agreed by the government in November 2008 in response to Dame Carol Black’s report on the health of the workforce, Working for a healthier tomorrow. The report stressed that work improved people’s physical and mental health and helped them to make a faster recovery. But it pointed out that “much of the current approach to the treatment of people of working age, including the sickness certification process, reflects an assumption that illness is incompatible with being in work”.

The report, itself part of an agenda to tackle benefit dependency and encourage health and well-being at work, advocated early intervention to prevent short-term sick leave from developing into long-term sickness absence and unemployment. So alongside the development of a fit note, it proposed giving occupational health a wider remit and bringing it into the mainstream of health services through a “Fit for Work” service. This would provide treatment and advice for people in the early stages of sickness absence, referring patients to a wide range of support, including financial advice and housing, as well as more traditional options, such as physiotherapy. The government has embraced the report enthusiastically and launched 10 Fit for Work pilot schemes along with other initiatives (see list below).

Lord McKenzie, a minister at the Department for Work and Pensions (DWP), believes that a consensus has emerged in the wake of the report and as a result of government consultation last year on implementation. He describes it as a “win, win, win” situation, helping: the individual to avoid long-term absence and unemployment; the employer to retain skilled and knowledgeable staff and pay less for sickness cover; and the taxpayer to save on benefits.

Dame Black, the UK’s national director for health and work, reported that the cost to the economy of sickness absence and worklessness associated with working age ill-health amounted to more than £100 billion a year – “greater than the current annual budget for the NHS and equivalent to the entire GDP of Portugal”. Mental ill-health soaks up between £30 billion and £40 billion of this.

Although these figures have been questioned, the fact remains that sickness absence is very costly and few would support the status quo in which 600,000 people a year in the UK come out of work and onto incapacity benefits.

But while the bodies consulted over the reforms – including the CIPD – support the principle, there are concerns among the doctors, line managers and HR professionals who have to implement them.

An Institute for Employment Studies survey of 50 managers last year showed that only 10 were completely positive about fit notes, while 21 were open-minded, with some concerns. Eleven saw no benefit to the proposals. Worries included the ability of GPs to deal with occupational health, the danger that managers would misinterpret fit notes or be unable to make adjustments for people and fears that there would be more work for employers, particularly HR.

Among the critics is Gill Hibberd, director of people and policy for Buckinghamshire County Council. She agrees that trying to get people back to work more quickly is “laudable and sends out the right message”. But she describes the fit-note strategy as “flawed”.

“To start with, the traditional role of the GP is to be a patient advocate and look after the patient and maintain confidentiality. The new fit note is asking the GP to play a role more akin to occupational health. I think a massive amount of education for GPs is needed and the government isn’t investing enough.

“Second, the information on the fit note is only as good as that given to the doctor by the employee about their work – they may not see it in the same way as the employer. Lastly, the focus is on long-term sickness absence, whereas persistent short-term absence is the bigger problem for employers.”

In place of the fit-note scheme, she advocates an occupational health specialist serving every major GP practice or group of practices. They would provide advice to GPs and patients within the NHS and be able to liaise with employers in a way that GPs are not empowered to do because of patient confidentiality – a more comprehensive scheme than the current government initiatives.

Some of these concerns are also echoed by GPs. Dr John Canning, a GP in Middlesbrough and a member of the BMA’s general practice committee, says: “I know what people do in an office, but not in a steelworks or a local factory. And I don’t know what an employer can do to mitigate the circumstances of work. That needs someone on the ground in touch with workplace issues.”

Although Canning, like the BMA, supports the fit-note scheme, he also agrees that the doctor-patient relationship can come under strain when the doctor is trying to persuade people they are capable of work.

A European survey, cited in a 2003 report, A vision for health, safety and rehabilitation support in work for Great Britain, showed that the UK had the lowest level of occupational health provision in the developed EU, covering only 34 per cent of workers. Canning believes, like Hibberd, that more specialists need to be trained. But others argue that there is a more pressing need to train GPs themselves in occupational health – a point highlighted in research carried out by Richard Roope, a GP and occupational health specialist in Hampshire.

He asked 113 GPs in a primary care trust how long after specific illnesses patients suffering no complications should go back to work. The answers revealed an extraordinary variation.

For example, opinions on how much time a woman needed off sick after a hysterectomy varied from two weeks to 13 weeks. More than three-quarters of the replies did not accord with government evidence-based guidelines.

The study, published in the journal Occupational Medicine in December, also showed that almost two-thirds of GPs had not received any training in sickness certification and the average amount of training for those who had was only four hours. Only a third of the GPs surveyed were aware that the government had guidelines on sickness certification and even fewer (20 per cent) actually used them.

In an effort to fill this training gap, the DWP is part-funding a series of half-day workshops run by the Royal College of General Practitioners in preparation for the new fit note. So far, more than 1,000 GPs have signed up and the DWP hopes that between 3,000 and 4,500 will be covered by March 2011. But some argue that this is not enough. The Society of Occupational Medicine supports the workshops but wants occupational health to become part of the medical school curriculum.

If GPs feel under-supported, what has been done to help employers? So far, very little – although as PM went to press, new guidance created with the help of business groups including the CIPD, was about to be released by the DWP.

The news will come as a relief to many in HR including Beverley Fairbank, HR manager of the Land Rover plant in Solihull. She is more positive about the fit note than Gill Hibberd, but one of her big concerns has been the lack of information: “Quite a few of us saw the consultation documents. But we didn’t communicate them widely to line managers at that stage because the details might have changed,” she says.

Worried HR professionals – and lawyers – have been asking, for instance: will they be forced to make costly adjustments to accommodate someone who six weeks later might be perfectly fit? What happens if an employee has been refused reduced hours in the past but is now recommended to return part-time?

Lord McKenzie stresses that if adjustments are too costly, unworkable or simply not worth the trouble, the terms of the fit note are not binding. The employee would simply revert to being off sick. This also applies to individuals who may resume work and then find they can’t manage it.

But he believes that most adjustments will not be costly or hard to implement: “GPs are not saying that these sorts of adjustments can be made, but are making suggestions. For instance, someone with mobility problems might work on the ground floor. Or if they have suffered work-related stress, a buddy system might help. It doesn’t follow that the employer is able in all circumstances to make these adjustments. If the employer cannot accommodate the person, the note will be accepted as sufficient for saying that someone is not fit for work.”

But, as Graham Smith and John Canning both point out, the behaviour of line managers is critical in these situations. “It’s the line managers who have to deal with it and sometimes it’s easier for them if the sick person isn’t there,” Canning says.

To help, the CIPD, with the British Occupational Health Research Foundation, has commissioned research to examine which kind of line manager behaviour works best with employees returning to work after heart disease, cancer, back pain or stress, anxiety or depression. The study will lead to a competency framework and advice published in the spring.

“The challenge is about managing the return to work in a more co-ordinated and successful manner,” says Ben Willmott, senior public policy adviser at the CIPD. “For instance, quite often people come back in and are still getting full pay because of their contracts, but are working part-time hours, and their colleagues resent this. Or they come back and find they have new colleagues or systems have changed. So the manager has a role in giving them clear objectives and talking to them regularly.”

One man who found his return to work more than a little challenging was Adrian Price, who has since found a new, voluntary role as co-ordinator of the Walsall Heart and Stroke Support Group. A few years ago, while working for a large company, he had heart surgery and went back to his office job part time. He says all was fine until the management team changed and started pressing him to return to full-time work. After a few months, he was made redundant.

The group he now runs is testing a scheme to help employees and their organisations to manage their return to work. The Walsall Return to Work Service, for heart and stroke patients, promotes a seven–step process involving the appointment of a case adviser, the creation of a personal return-to-work plan and a communications strategy, in which the adviser keeps all parties involved in the plan updated with the patient’s progress. Crucially, the adviser mediates with the individual’s employer. A similar planned approach is recommended by the CIPD.

Clearly, training and support is as important for line managers as GPs. Beverley Fairbank is among those who have tackled this. She recently refocused Land Rover’s absence management programme for line managers on managing staff rehabilitation after sickness in anticipation of the new fit-note system.

Fairbank estimates that her team is making temporary adjustments for about 8 per cent of people at any one time. “We are lucky to have a fully qualified occupational health person and access to mental health support,” she says. “But it must be very difficult for a small business.”

Graham Smith, now seeing things from a patient’s point of view, looks back with horror at his younger self, when he managed a group of workers caring round the clock for elderly people and had to maintain minimum staffing levels. “We had high rates of sickness absence and I wasn’t very sympathetic,” he recalls. “I would say we definitely had higher absence because of my failure to engage people.”

He agrees that line managers need training to apply the new system. But, most of all, he says, line managers appreciate help from HR, working with internal or external occupational health professionals, who in turn liaise with GPs. In other words, it’s a three-legged race – and without co-operation no one will reach the finishing line.

Back to work: government initiatives to pave the way
- Occupational health advice line: nine phone lines to advise small and micro business managers on individual employee occupational health and mental health issues. 

- Fit for work services: 10 pilot schemes to help support people to stay in work, or return to work more quickly, if they develop a health condition or impairment. 

- Health Work and Well-Being Challenge Fund: £4 million grant from the Department for Work and Pensions for small businesses to establish health and well-being initiatives.

- Health, work and well-being co-ordinators: one in each region, to promote action and share best practice, focusing on smaller firms, and to administer the challenge fund.

- Pathways Advisory Service: started in 2005 and expanded in 2008. Jobcentre Plus advisers work from some GP surgeries, giving back-to-work advice for patients receiving employment support allowance and incapacity benefit.

- Working our way to better mental health – a framework for action: A cross-government national mental health and employment strategy to help people back to work, backed by a support package launched in December.

- National education programme for GPs: half-day workshops from June 2009 to March 2011.

- National Centre for Working-Age Health and Well-Being: plan for an independent body providing information and encouraging research on the health and well-being of working-age people. The DWP is expecting to seek tenders from February/March.