It was good to see reports this morning that Health Secretary, Alan Johnson, has agreed that GPs should no longer issue sick notes to patients excusing them from work, but that instead “fit” notes should be issued, focusing on what their patients can do at work rather than what they can’t.

At the beginning of this year, I initiated a debate in the House of Lords on precisely this issue.  My focus was on back pain – or in Parliamentary language, musculo-skeletal disorder.  As I ponted out, over 2.5 million people in the UK visit their GP with back pain each year.  At any one time, a third of the population is suffering with back problems and it is estimated that up to 80% of the adult population will suffer significant back pain at some time in their life.

Most people – certainly fellow-members of the House of Lords – know how debilitating severe back pain can be.  It affects mobility and agility and reduces stamina.  The pain affects concentration, the ability to think rationally, and the pain affects the sufferer’s mood, may make them irritable and can lead to severe depression.

According to the Health and Safety Executive back pain was responsible for 9.5 million lost working days in 2005/6 – at a cost to society in 2007 prices of over £7 billion.

 

So, what happens when these people visit their GP with a complaint? All too often, out of compassion and concern for their patient, the GP will issue a sick note advising they take time off work.  They may be advised to stay home for weeks or months, while they wait for tests, then treatments, to make them feel well again.  

 

For those of us who fall ill with flu or minor infections, and spend a week in bed, this probably sounds like common sense.  However, for many people with long-term acute conditions it may not always be the right approach.  The physical conditions of work may indeed have caused or will aggravate a musculoskeletal condition, but equally prolonged inactivity may well make the condition worse.  Moreover, absence from the work environment, and the associated isolation, may worsen the depression associated with the pain and make recovery even less likely.

 

Certainly, many GPs and many employers mistakenly believe that sufferers from musculoskeletal disorders must be 100% well before any return to work can be contemplated.

I contrasted this approach with that of Transport for London (TfL), of which I was then an Advisor to the Board (before Mayor Johnson sacked me).  TfL’s occupational health service has been pro-active in tackling back pain.  There has been an in-house physiotherapy service for low back pain since 2001.  Attractive educational materials including a CD-ROM with amusing video clips and job-dependent exercises for staff were developed and widely distributed in 2005-6 and are now provided as a part of some types of training. 

A back exercise class has been introduced and is run three times a week at different times to allow employees to attend without interfering with their shifts.  Employees are encouraged to continue to attend once their back pain is resolved, if they would like to, in order to keep up the level of back fitness that they have achieved.

 

A pilot study carried out in 2001 demonstrated that employees who received physiotherapy intervention returned to work 12.6 days sooner than predicted using historical data when employees did not have access to a physiotherapy service.

 

A more recent study in 2003/4 found that employees who were referred to the back pain service after more than 6 weeks absent had twice the length of absence of those referred within 6 weeks and four times the absence of those referred within 2 weeks. Hence early referral for physiotherapy significantly reduced further time off. Sitting at home waiting for the problem to resolve just prolonged further time off.

 

Moreover, only 13% employees referred to the low back pain service in September to December 2005 for first episode low back pain had a recurrent episode leading to absence during the following year. This compares favourably with recurrence rates of 26-37% reported in research. 

The evidence is that with enlightened and supportive  employers an early return to work is in everyone’s best interest: it is better for the individual, it is better for their employer, and it saves in NHS and benefits costs.  Ending the sick note culture and replacing it with a fit note culture has to be the right approach.

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