The issue of "long-term" fit notes for depression in the UK: patient, GP and general practice variation.

Background: Depression is an important cause of certified sickness absence in the UK. It is not known what factors are associated with variation in length of sickness certificates issued by the GP to the depressed patient.Aims: The purpose of the study was to identify patient, GP and practice factors associated with the issue of a long-term (> 4 week) fit note for depression.Methods: Sixty-eight UK general practices collected sickness certification data for 12 months.Results: Over 35% of 8127 fit notes issued to 3361 patients for depression were classed as long-term (over four weeks in duration). Having previous fit notes for depression, not having "may be fit" advice on the fit note, older patient age, the patient living in a deprived neighbourhood and a higher practice deprivation status were all significant predictors of a long-term fit note. Depression fit notes issued by female GPs to female patients were less likely to be long-term. Other GP factors were not significant predictors of a long-term depression note.Conclusions: Reducing the number of long-term sickness certificates issued to people with depression should be considered part of return-to work and job retention strategies.

Change in diagnosis on fit notes within an episode of certified sickness absence.

BACKGROUND: Little consideration has previously been given to the implications of a change in diagnosis during a sickness certification episode. OBJECTIVE: To report the extent and patterns of change in diagnosis and to identify factors associated with likelihood of change. METHODS: Sixty-eight general practices in the UK recorded details of sickness certificates (fit notes) issued to patients in a 12-month data collection period. Diagnoses on fit notes were assigned to modified READ categories. RESULTS: Over 23% (3841/16400) of episodes consisting of more than one sickness certificate had a change in diagnosis during the course of the episode. Over 4% (438/10398) of initial physical health episodes had a later mental health diagnosis. Lowest rate of change was found within episodes with an initial mental health diagnosis, the highest when an unspecified physical symptom was entered on the first fit note in the episode. A change in diagnosis was more likely when the total duration of the episode was longer, the episode included more fit notes and the patient was living in a socially deprived neighbourhood. Episodes where the patient had been issued fit notes by more than one GP were more likely to have a change in diagnosis. CONCLUSION: Change in diagnosis on fit notes is much less common when the patient has a psychological health problem.

Factors associated with the length of fit note-certified sickness episodes in the UK.

OBJECTIVES: To identify diagnostic, patient/employee, general practitioner (GP) and practice factors associated with length of certified sickness episodes. METHODS: Twelve-month collection of fit note data at 68 general practices in eight regions of England, Wales and Scotland between 2011 and 2013. Secondary analysis of sick note data collected at seven general practices in 2001/2002. All employed patients receiving at least one fit note at practices within the collection period were included in the study. Main study outcomes were certified sickness episodes lasting longer than 3, 6 and 12 weeks. RESULTS: The data from seven practices contributing in 2013, and a decade previously, suggest that periods of long-term sickness absence may be falling overall (risk >12 weeks absence, OR=0.65) but the proportion of mild-moderate mental disorder-related (M-MMD) episodes is rising (26% to 38%). Over 32% (8064/25 078) of fit notes issued to working patients in the 68 practices were for a M-MMD. A total of 13 994 patient sickness 'episodes' were identified. Diagnostic category of episode, male patients, older patient age and higher social deprivation were significantly associated with the >3 week, >6 week and long-term (>12 week) outcomes, and GP partner status with the long-term outcome only. CONCLUSIONS: In the context of a rapidly changing legislative environment, the study used the largest sickness certification database constructed in the UK to enhance the evidence base relating to factors contributing to long-term work incapacity.

Cost-effectiveness of interventions to return employees to work following long-term sickness absence due to musculoskeletal disorders.

BACKGROUND: Sickness absence costs the UK economy around £20 billion per year. This study aims to assess the cost-effectiveness of interventions to return employees with musculoskeletal disorders to work, one of the major causes of long-term sickness absence, using a mathematical model. METHODS: A Markov model was developed to assess the cost-effectiveness of three interventions: a workplace intervention; a physical activity and education intervention and a physical activity, education and workplace visit intervention. Extensive sensitivity analyses were undertaken to assess the impact of uncertainties upon the model results. RESULTS: All interventions assessed are estimated to have a cost per quality-adjusted life year gained below £3000 compared with usual care within the UK from a National Health Service (NHS) or societal perspective. Moreover, any intervention which returns at least an additional 3% of employees to work and costs less than an additional £3000 per employee, is likely to be considered economically attractive compared with usual care, relative to other interventions routinely funded by the NHS. CONCLUSIONS: This is the first economic evaluation in this area which extrapolates data beyond trial follow-up and synthesizes evidence from numerous sources. This sort of modelling approach should be considered for informing other public health policy decisions.

Workplace involvement improves return to work rates among employees with back pain on long-term sick leave: a systematic review of the effectiveness and cost-effectiveness of interventions.

PURPOSE: Long-term sickness absence among workers is a major problem in industrialised countries. The aim of the review is to determine whether interventions involving the workplace are more effective and cost-effective at helping employees on sick leave return to work than those that do not involve the workplace at all. METHODS: A systematic review of controlled intervention studies and economic evaluations. Sixteen electronic databases and grey literature sources were searched, and reference and citation tracking was performed on included publications. A narrative synthesis was performed. RESULTS: Ten articles were found reporting nine trials from Europe and Canada, and four articles were found evaluating the cost-effectiveness of interventions. The population in eight trials suffered from back pain and related musculoskeletal conditions. Interventions involving employees, health practitioners and employers working together, to implement work modifications for the absentee, were more consistently effective than other interventions. Early intervention was also found to be effective. The majority of trials were of good or moderate quality. Economic evaluations indicated that interventions with a workplace component are likely to be more cost effective than those without. CONCLUSION: Stakeholder participation and work modification are more effective and cost effective at returning to work adults with musculoskeletal conditions than other workplace-linked interventions, including exercise.

Recurrence of sickness absence episodes certified by general practitioners in the UK.

BACKGROUND: Compared to other areas of sickness certification, recurrence of certified sickness absence has been relatively under-researched. OBJECTIVES: This study aims to report the extent and patterns of recurrence and to identify factors associated with higher rates of recurrence. METHODS: Sickness certification ('fit note') data were collected from 68 general practices in eight regions of the UK for 12 months. RESULTS: Twenty percent of 31,453 patients in the study had a recurrent certified sickness episode, with over half of these having the second episode in the same diagnostic category as their first. Mental health problems accounted for over a half of all days certified in same-diagnosis recurrent episodes. Male gender, residing in an area of social deprivation, a longer episode of initial certified sickness absence, not having return to work ('may be fit') advice in the first episode, having a mental disorder or musculoskeletal (particularly back) problem were all independently associated with a higher incidence of recurrence. CONCLUSION: Differential risk of recurrence needs to be considered when designing return-to-work interventions. Evaluation of effectiveness of interventions (particularly for sickness absentees with mental health problems) has to consider the sustainability of employment after a return to work.

Sickness certification for common mental disorders and GP return-to-work advice.

UNLABELLED: Aim To report the types and duration of sickness certification for different common mental disorders (CMDs) and the prevalence of GP advice aimed at returning the patient to work. BACKGROUND: In the United Kingdom, common mental health problems, such and depression and stress, have become the main reasons for patients requesting a sickness certificate to abstain from usual employment. Increasing attention is being paid to mental health and its impact on employability and work capacity in all parts of the welfare system. However, relatively little is known about the extent to which different mental health diagnoses impact upon sickness certification outcomes, and how the GP has used the new fit note (introduced in 2010) to support a return to work for patients with mental health diagnoses. METHODS: Sickness certification data was collected from 68 UK-based general practices for a period of 12 months. Findings The study found a large part of all sickness absence certified by GPs was due to CMDs (29% of all sickness absence episodes). Females, younger patients and those living in deprived areas were more likely to receive a fit note for a CMD (compared with one for a physical health problem). The highest proportion of CMD fit notes were issued for 'stress'. However, sickness certification for depression contributed nearly half of all weeks certified for mental health problems. Only 7% of CMD fit notes included any 'may be fit' advice from the GP, with type of advice varying by mental health diagnostic category. Patients living in the most socially deprived neighbourhoods were less likely to receive 'may be fit' advice on their CMD fit notes.

Factors associated with prevalence and types of 'may be fit' advice on fit notes: a cross-sectional primary care analysis.

BACKGROUND: The 'fit note', with the opportunity for the GP to advise that a patient 'may be fit' to do some work, was introduced in April 2010. AIM: To estimate numbers of fit notes with 'may be fit' advice, the types of advice, and factors associated with any inclusion of such advice in the fit note. DESIGN AND SETTING: Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland. METHOD: Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months. RESULTS: The 'may be fit' box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to 'amend duties' of patient as a prerequisite for return to work (included in 42% of all notes containing any 'may be fit' advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any 'may be fit' advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note. CONCLUSION: Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers).

NICE guidance on long-term sickness and incapacity.

Long-term sickness absence and incapacity benefits (disability pension) rates have increased across industrialised countries. Effective measures are needed to support return to work. The recommendations of this guidance were informed by the most appropriate available evidence of effectiveness and cost-effectiveness. Public health evidence was provided by research using a variety of study designs that attempted to determine the outcome of a particular intervention by evaluating status before and after the intervention had been effected, and was not limited to randomised control trials. Where the evidence base was depleted or underdeveloped, expert witnesses were called to give their opinion on the best available evidence and emerging interventions. The process enabled challenge and contestability from stakeholder groups at different points as the guidance was developed. Forty-five heterogeneous studies were included in the review of interventions to reduce long-term sickness absence and transitions from short-term to long-term absence (mainly covering the former and also mainly examining musculoskeletal conditions). The analysis of evidence was restricted to descriptive synthesis. Three general themes emerged from an analysis of the studies that were more likely to report positive results: early interventions; multidisciplinary approaches; and interventions with a workplace component. Two further reviews were undertaken, one on interventions to reduce the re-occurrence of sickness absence, which identified seven studies on lower back pain, and concluded that early intervention and direct workplace input are important factors. The final evidence review focused on six studies of interventions for those in receipt of incapacity benefit. The evidence was that work-focused interviews coupled with access to tailored support are effective and cost-effective interventions. Practitioners should consider the impact of interventions and management options on work ability for patients of working age. Work ability should be considered a key outcome for future intervention studies.