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The line between fit and sick

On 6 April 2010, the new ‘fit note’ system went live. How GPs will apply it is as yet uncertain, but Foresight highlights some of the issues employers may need to address.

The fit note gives GPs new choices when assessing an individual’s fitness for work. Instead of recommending that patients are fully fit or fully unfit for work, a GP can now advise patients either that they are not fit for work or that they “may be fit for work under certain conditions”. These conditions include a phased return to work, altered hours, amended duties and workplace adaptations. The GP can add comments on relevant factors, such as the “functional effects” of the individual’s condition.

“The actual idea behind fit notes is difficult to find fault with”, says Dave Manning, Principal at Mercer. “The argument that work is good for you has been proved, therefore, in theory the more people can stay in work in some capacity, the better it is for them. However, in practice, there could be a few teething problems.”

Problems may arise because the fit note represents a substantial culture change. GPs may not have sufficient knowledge to determine whether certain workplaces or changes to working hours could enable an individual to return to work.

“One of the potential problems is that GPs may not always feel comfortable or capable of making that decision”, says Dave. “GPs could also face some resistance from individuals wanting and expecting an old-fashioned sick note or from potential income protection claimants.”

Dave adds that if an individual is resistant to the suggestion that he or she may be fit for work, the question is how the GP will react: “GPs could elect to make a ‘not fit for work’ decision – in which case, what has really changed?”

If there are potential difficulties for GPs in adapting to the new fit note system, employers too could face some challenges.

Firstly, the doctor’s advice is not binding on the employer, who must still take responsibility for considering fully whether an individual is capable of returning to work. It may be necessary to involve occupational health professionals to assess an individual’s fitness, including the appropriateness of any adaptations to the workplace or changes to the role suggested by the GP.

“Employers also need to make sure they engage with any employee who receives a fit note”, comments Dave. “They need to take note of the doctor’s comments and ascertain if it is appropriate for the employee to return to work. There could, of course, be some conflict if individuals feel that their views are being overlooked.

“However, should the employer decide for whatever reason that it is not appropriate to return to work, the employer should make clear that there is no right to appeal”, he adds.

Another issue is that a fit note could result in additional costs for employers, including the increased numbers of occupational health assessments. There could also be costs incurred in adapting the work environment.

“There is a big issue around health and safety risk assessments”, points out Dave. “These will need to be conducted to make sure any changes to an individual’s working conditions do not contravene statutory regulations. For small- and medium-size employers, all such costs could be felt particularly keenly.

“The introduction of the fit note system is likely to make employers review sickness absence policies and processes”, Dave says. There could also be new challenges in the management of income protection claims – for example, where a claim is adjudicated against an individual’s normal role, but the GP has suggested activities that are outside that role description.

Employers will need to communicate clearly with staff about the new system, how it works and what is expected of them. “Otherwise”, says Dave, “I can see a lot of calls to the HR department from line managers saying, ‘I’ve got a fit note – what do I do now?’ ”

For further advice on fit notes, please contact Dave Manning on +44 (0)121 6443695 or by e-mail.

Care as a priority

The future of the NHS is frequently debated, particularly in an election year. But for most employers, private medical health insurance has become an essential benefit for key personnel. Foresight considers the issues.

When Labour first came to power in 1997, the party pledged to increase UK health spending as a proportion of GDP to the EU average. That has largely been achieved. Real spending on the National Health Service has risen dramatically, and the proportion of GDP injected into the NHS is now close to the EU average of around 10 percent.

Improvements in service delivery have followed. “The most visible impact has been for cancer and heart disease patients”, says Paul Ashcroft, Principal at Mercer.

“Traditionally there were long waits between diagnosis and treatment. The situation still varies by district, but generally things have got a lot better.”

The picture is perhaps more confusing for elective procedures, with greater variations across the country. But even where the 18-week target wait has been achieved, that period still equates to considerable time off work for those affected. “For most people, that length of wait is still unacceptable”, says Paul.

Continued improvements in the quality of NHS services appear in doubt. “Looking into the crystal ball, the NHS will be subject to financial constraints”, Paul predicts.

“We may see a worsening in funding and in the NHS’s ability to provide services. If anything, general waiting times will increase. So I expect demand for private medical insurance will remain pretty stable.”

Providing such cover for senior staff has become the market norm for employers. “Medical cover is an expected benefit”, Paul says. “In order to attract the right people, it’s got to be part of the package.”

At the same time, employers increasingly appreciate the value from providing private medical insurance (PMI) as a benefit. “They get people back to work more quickly and have reduced absence.

There’s also the whole health and well-being aspect – people feel looked after by their employer.” Employers of all sizes appreciate the necessity of PMI cover, but there is perhaps an inverse link between size and impact. “The smaller the company, the more it relies on key people”, Paul says. “Employers can’t afford to have people out of the workforce for long.”

If providing PMI to employees has become expected, choosing the right cover and insurer is a complex challenge for employers.

At the top end of the market, for large health plans, there is only a handful of providers”, Paul says. “In the mid-market, there are a number of insurers. They offer cover which on the face of it looks broadly similar, but when you dig into the detail there are fine points of difference.” For example, insurers have different policies on the treatment of cancer in terms of the drugs they will support or length of treatments.

Alongside such product complexities, there are also variations in terms of cost.“Price is a consideration for employers”, Paul says. “It is a competitive market, so some insurers’ quotes will be cheaper than others.” However, cheap cover has its downsides if that means poor service. “It’s important that employers understand that there are differences in the quality of insurers’ administration”, notes Paul. “At Mercer, we conduct a biannual survey on insurer administration services, looking at issues such as claims handling. We ask organisations how they rate their insurance provider, collate that data and make it available to clients during the insurer selection process.”

Ultimately, employers need to establish their key objectives for PMI in order to achieve their preferred balance between cover, cost and service levels.

“We generally find that employers in the mid-market are more focused on cost than some bigger employers”, Paul says. “But looking at how the market is evolving, mid-market employers also want a product and service that’s easier to understand and to manage.”

Mercer offers a comprehensive range of consulting services, from the integrated approach of helping companies assess and minimise health-related costs through greater alignment and coordination of their health supply chain, to assistance with the selection of a single provider.

For further advice, please contact Paul Ashcroft on +44 (0)20 7178 5205 or by  e-mail.