Long-term sickness and incapacity

This article provides a brief summary of the recommended assessment and interventions to help long-term sickness and incapacity. GPs always have a role in the management of patients with long-term sickness and incapacity but the nature of the role varies greatly with the type of problem causing long-term sickness and other resources available - eg, at the place of work.

The role of a GP may include providing appropriate certification when required, acting as advocate for the patient, continued support and care for any underlying health problem and supporting and/or providing any specific interventions to help the person return to work.

What is considered long-term sickness?

There is no commonly agreed definition of long-term or short-term sickness absence. The National Institute for Health and Care Excellence (NICE) guidance defines:¹

• Short-term sickness absence as lasting up to four weeks.

• Recurring short-term sickness absence as a number of episodes of absence from work, each lasting less than four weeks.

• Long-term sickness absence (including recurring long-term sickness absence) as absences from work lasting four or more weeks.

Initial enquiries to be made by the employer¹

• Within four weeks of starting sickness absence (or following recurring episodes of sickness absence), someone suitably trained (eg, an occupational health physician, nurse, human resource specialist or the person's line manager) should contact the employee who has taken long-term sickness leave or recurring short- or long-term sickness absence and make initial enquiries regarding:
  

  • The reasons for sickness absence.

  • Whether they have received appropriate treatment.

  • How likely it is that they will return to work.

  • Any perceived (or actual) barriers to returning to work (including the need for workplace adjustments).

• Consider the employee's age, sex/gender and the type of work they do. These factors may affect their speed of recovery and ability to return to work.

• Consider any incentives or financial issues which may encourage or discourage a return to work (for example, any impact on pay).

• If action is required consider if:
  

  • A detailed assessment is needed to determine what interventions/services are required and to develop a return-to-work plan.

  • A case worker may need to be appointed to co-ordinate a detailed assessment, deliver any proposed interventions or produce a return-to-work plan.

• Case workers do not need a clinical or occupational health background but should have the skills and training to act as an impartial intermediary.

Detailed assessment by the employer or case worker¹

If the initial assessment has shown that a detailed assessment is needed, arrange for the relevant specialist/s to undertake it (or different aspects of it) with the employee. The detailed assessment could include one or more of the following:

• Getting further specialised advice on diagnosis and treatment or the need for further tests or sick leave.

• This could be achieved through a referral to an occupational health adviser, a GP with occupational health experience or to another health specialist such as a physiotherapist (or by encouraging the employee to self-refer).

• Use of a screening tool to assess how likely it is the employee will return to work.

• A combined interview and work assessment.

• Deciding whether any interventions or services are needed.

• Developing a return-to-work plan.

Combined interview and work assessment¹

This should involve one or more specialists and the line manager. (The specialist might be a physician, nurse or another professional who specialises in occupational health, health and safety, rehabilitation or ergonomics.) It should evaluate:

• The employee's health and social and employment situation: this includes anything that is putting them off returning to work - for example, organisational structure and culture (such as work relationships) and how confident they feel about overcoming these problems.

• Their current or previous experience of rehabilitation.

• The tasks they carry out at work and their physical ability to perform them (dealing with issues such as mobility, strength and fitness).

• Any workplace or work equipment modifications needed in line with the Disability Discrimination Act (including ergonomic modifications).

Return-to-work plan¹

The return-to-work plan should identify the type and level of interventions and services needed (including any psychological support) and how frequently they should be offered. It could also
specify whether or not any of the following is required:

• A gradual return to the original job (phased return) by increasing the hours and days worked over a period of time.

• A return to some of the duties of the original job.

• A move to another job within the organisation (on a temporary or permanent basis).

Co-ordinating and delivering interventions and services by the employer¹

• Ensure the proposed interventions are appropriate for the employee.

• Ensure the employee is consulted and agrees to the proposals (it is important to establish their confidence and trust in the individual delivering the interventions).

• Keep in regular contact with the employee.

• Co-ordinate and support the delivery of interventions or services, including any return-to-work plan.

• Liaise with everyone involved (such as line managers and occupational health staff).

• Where necessary, arrange for a referral to relevant specialists or services. This may include:
  

  • Referral via an occupational health adviser to an appropriate health specialist, such as a GP with occupational health experience, a specialist physician, a specialist in occupational health, health and safety, rehabilitation or ergonomics, or a physiotherapist.

  • Encouraging the employee to contact their GP or occupational health service for further advice and support.

• Consider offering 'light' or less intense interventions, along with usual care and treatment, to those who are likely to return to work.

• Consider more intensive, specialised input when there is recurring long-term (or repeat episodes of short-term) sickness absence or where the outlook for a return to work is poor.

• Consider ways of helping people to overcome the barriers to returning to work, using psychological interventions.

• Where appropriate, offer a management programme for back problems.

Interventions to help a return to work¹

Intensive programme of interventions

Intensive support could be provided by a number of different specialists over a period of several weeks. This should be combined with the care and treatment they are already receiving. Examples of intensive support may include one or more of the following:

• Cognitive behavioural therapy (CBT) or education and training on physical and mental coping strategies for work and everyday activities (this may be combined with exercise programmes).

• Counselling about the issues involved in returning to work.

• Workplace modifications.

• Referral to specialised services (eg, physiotherapy or psychological services) or vocational rehabilitation or training.

Light or less intense interventions¹

This might include short sessions offering one or more of the following:

• Individual, tailored advice on how to manage daily activities at home and at work - eg, advice on the benefits of being physically active and on relaxation techniques.

• Encouragement to be physically active.

• Referral to a physiotherapist or psychological services.

Overcoming specific barriers to returning to work¹

Consider helping people to develop problem-solving and coping strategies to help them return to work.

• Low back pain: CBT in a group of 5-6 people combined with one-to-one sessions to increase each person's activity levels gradually ('behavioural-graded activity'), in addition to liaison with the employer to discuss a plan for returning to work.

• Musculoskeletal pain (women): CBT in a group of 5-6 people, with one-to-one telephone follow-up. CBT aims to reduce distress or change behaviour that is having a detrimental effect on people's health or well-being.

• Psychological or musculoskeletal problems: solution-focused group sessions.

• Stress-related conditions: CBT and contact with the employer.

• Whiplash injuries: progressive goal attainment programmes combined with physiotherapy or multimodal programmes.

Back problems¹

• To help employees with back problems, a back management programme could be delivered by a GP with occupational health experience, a specialist professional (eg, a physiotherapist) or a combination of professionals specialising in occupational health, health and safety, rehabilitation or ergonomics.

• The programme could comprise one intensive session covering:
  

  • The employee's attitude to health.

  • The structure and function of the back and posture and how these link to their symptoms.

  • Stress and coping strategies.

  • Posture exercises.

  • Relaxation training.

• It could also involve optional sessions to recap on learning and to discuss how they have put it into practice.

Unemployed people in receipt of incapacity or other similar benefits¹

• There is also a recommendation in the NICE guidance for bodies that commission services for people who are unemployed and claiming Employment and Support Allowance (ESA) - formerly called Incapacity Benefit. This includes the Department for Work and Pensions.

• NICE says that these bodies should commission an integrated programme to help claimants enter or return to work (paid or unpaid). The programme, which should be evaluated, should include a combination of interventions such as:
  

  • An interview with a trained adviser to discuss the help they need to return to work.

  • Vocational training, including that offered by the New Deal for Disabled People (for example, interview training, help producing a CV or help to find a job or work placement).

  • Help for people to manage their health condition (for example, programmes run by local health providers).

  • Financial measures to motivate them to return to work (such as return-to-work credit).

  • Support before and after returning to work (such as the services of a mentor or occupational health, or financial advice).

Employment and Support Allowance^{2 3}

• In October 2008, Employment and Support Allowance (ESA) replaced the existing system of incapacity benefits for new applicants.

• ESA provides financial support to disabled people or individuals with a health condition that affects their ability to work.

• The decision to award ESA is based on a range of information, evidence and independent medical advice, including that provided by a patient's GP.

• People can have a fit note to support their claim, signed by a registered nurse, occupational therapist, pharmacist or physiotherapist in addition to a GP or hospital doctor.

• Most patients will be assessed through an independent Work Capability Assessment, carried out by specially trained healthcare professionals and not the patient's GP.

• The aim of the work-focused health-related assessment is to explore the patient's views about moving into work and the support they need to help them get there.

• Applicants will join one of two groups, depending on their capability for work:
  

  • Those who can reasonably be expected to prepare for work will join the 'Work-Related Activity Group'. They will attend up to six work-focused interviews with a personal adviser to ensure they receive appropriate support, through a Pathways to Work Programme.

  • If the effects of an individual's health condition or disability are so severe that it would be unreasonable to expect them to prepare for work, they will join the 'Support Group'. These individuals will not be required to prepare for work and will receive additional financial help.