Workers’ fit-note: Innovations in teaching and research

1. Workers’ fit-note: Innovations in teaching and research EASOM Summer School (Teaching Psychosocial Risk Factors at Work) August 2015, Slovenia (Offline interim back-up USB version of presentation) R. Agius, L.Hussey, H.Davies, J.Dodman, A. Money, C.Rayner, D. Sen, N.Zarin, Y.Zhou. Centre for Occupational and Environmental Health, The University of Manchester http://www.medicine.manchester.ac.uk/oeh/

2. Structure of presentation • Background and Introduction • Research on ‘Fit-note’ • Teaching on ‘Fit-note’ • Online demonstration of methods of data-collection for research and of online learning, audit and benchmarking • (not in USB version of presentation, hence slides will be different from the ‘live’ presentation) • Preliminary evaluation • Conclusion and Discussion

3. Background and introduction • Primary prevention and, failing that, secondary prevention are the best ways of maintaining health. • However even when workers have suffered work related ill health and have sustained sickness absence for these or other reasons, every effort should be made to assist their rehabilitation and to reduce the risk of recurrence of ill health: • ‘Tertiary prevention’

4. Measures to achieve ‘tertiary prevention’ • ‘Structural’ / organisational measures such as laws, policies, protocols etc, e.g.: • “Working for a healthier tomorrow: review of the health of Britain’s working age population.Working for a healthier” (C. Black 2008). Recommendations included: • ‘Fit-note’ (introduced April 2010) • But – research needed • Education of doctors, workers, employers • But this need to be easy and effective and methods need to be developed and evaluated.

5. Has the fit note reduced general practice sickness certification rates? * • Summary of initial research methods: • GPs participating in THOR since mid 2005 and having limited training (usually from COEH) in Occupational Medicine • Target of 300 GPs in research network – but usually around 250 participating at any time • Incident cases of Work Related Ill Health (WRIH) reported prospectively and electronically using a time sampling method (online demonstration to follow) • Initial data base of 5517** consecutive prospectively reported cases (4 years before and 3** years after the ‘fit-note’ was introduced in April 2010) • *Based on Hussey et al Occupational Medicine 2015;65:182–189 (**but updated for the presentation)

6. GPs were asked (amongst other things) whether the patient was fit for work, and then had to select: • Yes – no further action required • No, sickness absence certified – GPs complete the number of days absence issued • Yes, but with workplace adjustment – GPs select from the following options • Phased return to work • Amended duties • Altered hours • Workplace adaptation • Other (GPs specify in text box)

7. Proportion of cases reported and days sickness absence certified by diagnostic category THOR-GP 2006 to 2013 N=6173 cases % of cases reported % of days sickness absence certified

8. Proportion of cases certified sick before and after introduction of the fit note (all cases)

9. Comparison of sickness absence certification by GPs: New cases of work-related mental ill-health for 4 years before and 3 years after the ‘fit-note’

10. Combining Research with Education COEH (The Centre for Occupational and Environmental Health) • Admits 80-100 postgraduates per annum (mostly physicians) to its award bearing postgraduate courses (Diploma, MSc) • Largest market share in the UK, with worldwide cover • Blended learning including longstanding high quality Web based resources • Innovative methods of research led teaching • Thousands of alumni are still associated through research as in THOR, as well as in CPD etc

11. Development of EELAB:Electronic, Experiential, Learning, Audit & Benchmarking Educational: To further enhance the quality and innovation of the Manchester programme of MSc, Diploma, and other postgraduate education and CPD in Occupational Medicine, through experiential learning with assessment. Contribution to clinical governance: To provide tools for self-audit against standards and benchmarking against peers. Research: To recruit, motivate, teach, retain, reward and improve the quality of participation of doctors in The Health and Occupation Research Network (THOR). To evaluate interventions e.g. tools for case management To undertake pedagogic research

12. feedback quiz learning resources keyword recognition Learning from real Occupational Medicine cases: Physician’s own management plan & The practice of hundreds of ‘peers’ Contrasted with Evidence Based Standards rash interaction diagnosis? proposed management… Audit vs Standards THOR database THOR database Benchmarking vs 1000’s of cases Benchmarking vs ~ 6000 cases, from our THOR database

13. Cases and resources on which EELAB is based • Based on ~ 6000 actual cases (experiential) of work related ill health and associated sickness absence reported to us in our THOR (The Health and Occupation Research Network) database • Cases reported by about 350 GPs • Learning is prompted by the actual case(s) seen by the doctors • Aiming, and currently achieving about 80% ‘cover’ by detailed educational resources of actual cases seen, e.g.: asthma, anxiety, back pain, bullying, depression, dermatitis, stress, upper limb disorders, etc (option to access independently of cases seen) • Electronicresources address; • Learning interactively including online assessment • Auditagainst evidence based or consensus standards • Benchmarkingdynamically against peers’ practice based on our THOR database

14. EELAB Online Demonstration … (NB- not all the following slides will necessarily be shown if the online demonstration works instead). http://www.coeh.man.ac.uk/eelab thor77 z*******6 http://www.coeh.man.ac.uk/eelab

15. How EELAB works …[1]… Actual case seen by physician with a networked PC: Physician enters data (e.g. as per a THOR report) in a secure webform with a physician-specific pre-approved login e.g.: Age and gender of patient Industry Occupation Relevant exposure Diagnosis Duration of symptoms / date of onset Sickness absence

16. How EELAB works …[2]… Physician invited to enter additional information (e.g. with a ‘drop down’ menu). This would follow on from the earlier ‘core’ data set, and would be such as: Further information about the job, exposures etc Whether diagnosis was based on history, specific tests [e.g. PEF] etc What action was taken / advice given [e.g. onward referral] Triggers for EELAB include: symptoms, diagnosis, occupational attribution, sickness absence / fitness / rehabilitation advice, further referral Physician still has option to access resources without a ‘case’

17. How EELAB works …[3]… Physician are offered the following: [L] Learning / CPD unit (stand alone online) -extant from our extensive resources, and specific to the case in question, or ‘virtual patients’, but also including descriptive data from our research [A] Audit of physician’s responses against standards eg evidence reviews (BOHRF) on Occupational Contact Dermatitis and Occupational Asthma, Faculty of Occupational Medicine guidelines for the management of Low Back Pain [B] ‘Benchmarking’ against the responses of other physicians who were presented with a similar case. Database from 5 years’ data being constructed, relevant feedback already piloted with samples of physicians. Aiming to cover > 80% of cases.

18. EELAB completion On completion of whatever of the above the physician chose, they are offered: An ‘e-certificate’ of whatever they had done e.g. Cases seen, educational resources and quizzes done Access to their online ‘record’ / ‘account’ so they can follow up progress, download certificates later etc The opportunity to feedback to us so that we can continue to improve

19. Feedback provided to the postgraduate physician depends on responses of the ‘subject’ and of their peers in relation to the ‘audit standard’ (usually evidence based). NB: Above ‘feedback’ would be qualified by more detail, explanations, links and appropriate ‘caveats’.

20. Output record from EELAB audit of process would specify: QUANTITATIVE SUMMARY OF ABOVE AUDIT Sampling frame: Cases managed from … to .. Case mix: … as specified … Items audited e.g.: Range (symptoms, signs, tests) ‘Fit note’ certification Referral, etc Standards: … as appropriate to cases … e.g. BOHRF, FOM Benchmarking: … vs peers … matched cases … OTHER COMMENT Automatic feedback relating (mainly) to: peer benchmarking and standards of process Self reflective textual notes e.g. lessons learnt, actions etc

21. Feedback by questionnaire or in person was generally very favourable Some physicians spontaneously reporting their use of EELAB for case based discussions / assignments. Comments suggesting better navigation and a wider range of clinical conditions to be supported by resources have guided further improvement of EELAB. Summary of Feedback

22. Qualitative feedback 'A nice neat tool....easy to use.. easy to navigate..' (TF) '..form easy to complete..' (DW) 'logical and clear organisation of information.. modules clear and easy to work through..' (AM) ' The current topics covered in your site are excellent. What others are in the pipeline and on what timescale?‘ (RW)

23. EELAB – recent developments [1] include… Improvements to portal entry page Addition of new clinical ‘triggers’ to the thesaurus such as diagnoses Addition of new trigger categories e.g. agents/ occupations … also prompting pop-up educational resource Increasing number of detailed topic areas Providing an easy summary of key points of guidance, good practice or summary of audit lessons (so doctors do not have to read the full document if they do not have the time) More resources linked e.g. NICE guidance, other audit standards – if possible focussing on ‘specific sentence’

24. EELAB – recent developments [2] include… More THOR data linked both graphically as pop-ups and in due course ‘dynamically’, and also links to papers Addition of relevant legal info. etc (feedback response) Better online portfolio ‘storage’ of CPD certificates, and of reported cases, with room for ‘self reflection’ – so as to aid in appraisal / revalidation portfolios Working to implement HTML5/CSS3 Exploring mobile devices options More for specialist OPs, not just trainees/ Dip. Occ. Med. GPs Preparation for further accreditation – others besides RCGP (UK)

25. Future research and development needs may include: • More quantitative research regarding the ‘fit-note’ in random representative samples of all GPs in respect of all causes of sickness absence. • Studies of more subtle effects of the ‘fit-note’ e.g. on duration of sickness absence, on workers’ well being and on recurrence rates • Better education of workers and employers as well as doctors • Controlled evaluation of education (e.g. using the online resource in an internally controlled randomised manner) • Other measures …

26. Summary conclusion • The introduction of the UK ‘fit-note’ in 2010 did not result in a significant change of the proportion of cases of WRIH in the THOR GP database who were given medically certified SA. • However this conclusion cannot necessarily be generalised to all GPs or all causes of sickness absence, nor does it exclude other possible effects • The ‘EELAB’ online resource focussed on the experience of actual individual cases as seen by the learning physician • It deliveried ‘Learning’ , ‘Audit’ and ‘Benchmarking’ with very encouraging feedback and accredited external review • The resource is undergoing further educational development especially for OPs

27. Discussion welcome Thank you for listening Please comment or ask questions