If you are ill and unable to work, you sign yourself off work for the first 7 days. This is self-certification.
After this, you need a doctors’ line – the so-called Fit Note. This is a certificate from the doctor to say that you are currently unable to work due to illness. There is now a space in the form for the doctor to say if you can work with amended duties, for example, seated duties only, or a return to work gradually with a build up to usual hours.
This line can be for days to months. After 28 weeks, the patient is goes on to ESA (Employment Support Allowance). The first phase lasts 13 weeks and is an ‘assessment’ phase’. By week 14, a Work Capability Assessment has been done. From there, the person can be refused further ESA and put onto job seekers allowance (unemployment benefit) instead. Or they can be given an extra ‘component’ of funds if the assessment shows they are unfit to work.
The assessments for ESA are currently done by Atos. The assessment is done without full access to the patient’s notes. The questions ask about best days, not worst days, and do not take into account the variability of conditions. If you have the Citizen’s Advice Bureau helping you with your appeal, you are 70% likely to win your appeal for Disability Living Allowance; otherwise you are 60% likely to succeed without an advisor. One may reasonably conclude that a successful appeal rate of this magnitude questions to accuracy of the assessments. Atos is a French electronics company, who employ doctors, nurses and physiotherapists to fill in computer-based forms. Atos have previously refused to answer my polite questions about how they train their staff and audit them, and about the evidence base for their questionnaire.
In the last couple of days, the news is that “People should be signed off for long-term sickleave by an independent assessor rather than their GP, a government review will recommend.” On the Today programme last week, Lord Freud said “At a certain point, that is, around 4 weeks, it’s important that there is an independent look to see what can be done to help people back into the workplace. Because that’s the point at which you can get into drift. If you start having have no support at all for the next 28 weeks…a very large proportion of people who then drift off into state support and very long term support, which is quite unnecessary in many cases.”
Is this true? Freud presumes that people have no support between 4 and 28 weeks of sickness absence. This isn’t true. GPs are responsible for reviewing these patients and ensuring that whatever it is that is keeping them from working is being treated, and that they are appropriately not working. The usual practice is to sign people off for a few weeks at a time.
The Fit Note, meantime, has no legal standing in terms of what the employer should provide. So if I say ‘suitable for mainly seated work’ the employer can say no, and the person cannot return to work. Or if I say ‘graduated return to work, start mornings only’, the employer can say no, and the person can remain on sick leave.
Freud believes that people off at 4 weeks are at very high risk of never working again. The idea, according to the Independent, is that a new independent body will see patients at 4 weeks and decide whether or not they should still be off on sickness absence. Freud says that the question will be asked “Can you do any job?”
The current sick notes are based on whether a person is fit or not to do their current job. My suspicion is is that the new scheme will assess ability to do any job. We haven’t been told if it will be a private company like Atos who will be charged with providing this new service, or how the assessments will be done, or what evidence there is for getting people back to work once they have had the assessment. How much will this company be paid, and will they be told to get a certain percentage of people back to work – just as Atos has been told to do? I am also concerned that this new scheme will make vulnerable people worried and anxious about failing the assessment.
I have no doubt that there are some people who are on long term sickness benefit who are capable of some kind of work. From my perspective though, this group is a minority. Most people want to work, for economic as well as personal reasons, and many people whose illness renders them unfit to work are scared about losing their job as well as frustrated that they cannot work.
What worries me about the review and Freud’s interview is the presumption that the majority of people on long term sick leave are fraudulent and/or capable of working. This hasn’t been borne out by ESA assessments, which have found that only about 1 in 3 people on long term sick leave are fit for work.
GPs are not occupational health doctors. But GPs often know patients well, and also know the advantages of work over unemployment. Equally, though, sickness means that some people cannot work. I am concerned that this isn’t being accepted by government – in the same way that the NHS is being disparaged for being a ‘national sickness service’. Of course it is – and of course, sometimes, through sickness, people cannot work.
The one thing that sounds like good news for employees with chronic illness – tax breaks for their employers – could be overshadowed by the presumption that sickness absence is always, or usually, inappropriate. It’s sometimes necessary, and a decent society should ensure that we care for sick people with sensitivity and respect. Removing GPs from sanctioning all sick leave needs of longer than 4 weeks seems both bad for patients and an overstatement of the misuse of the forms.
And what’s really irritating is that the publicity has not been accompanied by release of the policy.
Margaret McCartney is a Glasgow GP who writes for various bits of the media, mainly about evidence based medicine.