The UK is facing a growing challenge in terms of the health of its
workforce. Every year almost a million workers take sick leave of over
a month in length and more than 300,000 people permanently leave their
employment due to illness or injury1. The situation is
becoming critical; is estimated to rise above 17 million in the coming
decades, affecting more individuals’ participation in the labour market2.
A system-wide cultural shift is needed throughout the NHS and the
public health system, recognising the therapeutic benefits associated
with employment and identifying work as an important health outcome.
Continuous engagement of patients in conversations about the
relationship between their health and work will be essential in
achieving this cultural shift and in helping people with long-term
conditions remain in employment.
Shared decision-making (SDM) takes into account both a professional’s
clinical knowledge and a patient’s lived experience and facilitates a
conversation as peers on a journey to find the best possible outcome
for the patient as an individual. AbbVie supported Professor Debbie
Cohen at Cardiff University to investigate how a new SDM tool that
focused on health and work could help patients return to work and
improve their management of their long-term condition. In addition,
the pilot explored how primary care can utilise the fit note to its
best advantage for patients.
Working with a wide range of stakeholders, a prototype SDM tool was
developed and subsequently reviewed by experts. This was then piloted
in both primary and secondary care settings in England and Wales. An
e-learning module to guide clinicians in how to use the SDM tool was
developed to support this pilot.
Nine GP practices trialled the SDM tool, with 32 GPs using the tool
and completing the evaluation and around 390 patients going through
the process. Of the GPs who
responded, 37% the tool was very
useful or useful when talking to patients about work and health. Only
9% said they did not find the tool useful. Around a fifth said that
the tool help them explore a patient’s confidence to return to work
and the obstacles and enablers for doing so. Some of the GPs also felt
that the SDM tool was a less confrontational way of having such a
More than 65% said that they wrote more ‘maybe fit’
notes or were able to complete the adjustments box on the form.
Importantly, 60% of those who took part in the pilot say they will
continue to use the tool with patients going forward.
While training was given to members of the British Society of
Rheumatology, there was lower engagement from secondary care and only
three individuals said they were adopting the SDM tool into their practice.
Analysis of the fit notes that were written during the pilot and
comparison to a baseline is ongoing.
The project has highlighted that the use of a simple tool (built
through working with key stakeholders) and simple learning through
innovative learning media, can enhance primary care practitioners
understanding of work as a health outcome. It has raised the
importance they give to these types of conversations and their
confidence in managing them. Of importance is that it seems to suggest
that the tool also supports their use of the fit note and participants
were more confident to write ‘maybe fit for work’ notes.
Nationally there have also been some important initiatives to embed
work as a health outcome into medical training. First, the UK
Government’ s recent document Improving lives, work, health and
disability which sets out the need to enhance medical education to
understand the importance of work as a health outcome and the
completion of the fit note. Second, the General Medical Council has
updated their Outcomes for Graduates which now states that all
students must be able to take a biopsychosocial history understanding
the importance of work as a health outcome and implement their
findings into their management plans.
The tool is now being developed into an app so that it can be more
accessible for users, and training modules for medical schools will be
developed so that undergraduates can familiarise themselves with the
app and how they can fulfil the expectations set out in Outcomes