International Journal of Physical Medicine & Rehabilitation
Open Access

Primary Care First Contact Practitioner’s (FCP) Challenges, Learning and Development Needs in Providing Fitness for Work and Sickness Absence Certification: Consensus Development

Cameron Black^{* *}Correspondence: Cameron Black, Department of Physiotherapy, University of Glasgow Caledonian, Glasgow, Scotland, Email:

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In the past, the support of those with illnesses was a matter of individual conscience, judgement and religious teaching. Its role was an act of human charity between an individual who was ‘sick’ and another with a close relationship. In our current society, with its ever-increasing complexity, it has become a compulsory and anonymous transaction, that is mediated by a welfare state, employee and employer. Working age adults who are sick are required to obtain a certificate from their consulting doctor (or in the United Kingdom an Allied Health Professional) before they can be paid statutory sick pay, and to satisfy their employer about the authenticity of this work absence. This process suggests that sickness must be assessed and measured to satisfy all stakeholders about the fairness and justice of it.

The reality of sickness absence certification (in the UK), since Lloyd George’s first National Insurance Act in 1911, is that sick certification is largely ineffective in preventing avoidable sickness. The ethical, professional, and regulatory context stifles the ability for healthcare professionals, especially General Practitioners (GPs), to set about effective change within a system that was created by lawyers and politicians.

In addition, the challenge currently is that since the National Health Service was created in 1948, the medical approach to certification provides evidence to suggest that doctors often take the path of least resistance. At a time now with exceptional COVID-19 response and healthcare demand, ethically it is difficult to expect doctors to consider an alternative. Confronting a patient, that may be fit for work, may be a timeconsuming and fruitless affair that prevents doctors from providing therapeutic care for those that need it most, and the challenge of reliably disproving an individual’s account of being medically incapable of work, is almost impossible. Medical training often imparts skills of disease detection, not illness verification. Even when injury, illness and disease is confirmed, it often does not tell us how a person feels or whether they can do their job. Our knowledge of many musculoskeletal presentations supports this. Recent evidence suggests that some GPs also deliberately do not initiate work-related conversations in fear of raising patient expectations for a Statement of Fitness for Work (Fit Note) as they do not feel adequately informed to offer advice or have the time to initiate discussions.

In the UK, the Departments of Health and Work and Pensions have outlined Legislation for extension of Fit Note sickness absence certification to other non-medical Allied Health Professionals to encourage patients to resume some work while managing a common health problem. More recently, AHPs have been increasingly using the UK’s AHP Health and Work report to provide information to the employee and employer on the functional impact of a patient’s reported problem. Doctor’s issue fit notes to people to provide evidence of the advice they have given about their fitness for work. They record details of the functional effects of their patient’s condition so the patient and their employer can consider ways to help them return to work. However, stakeholders acknowledge that the current system is not working, for example, only 6% of ‘Fit Notes’ or the Statements of Fitness for Work are deemed ‘may be fit for work’ even though most primary care consultations are deemed low risk.

Our work suggests that AHPs can take on this role, with further training and development. Opportunities exist for further exploration of the drivers and barriers for implementing workrelated conversations, sickness absence management and fitness for work strategies in primary care. A First Contact Practitioner (FCP) is a physiotherapist who is professionally qualified to treat patients without a referral from a GP or other healthcare professional. FCPs provide the first point of contact whereby those who visit a GP for a musculoskeletal (MSK) problem will instead have an appointment with an FCP. They see undiagnosed and undifferentiated conditions within primary care and may have extended roles of injection therapy and independent prescribing, they can refer onto specialist and secondary care and can send patients for radiology. They may be an ideal healthcare professional to overcome the barriers in fitness for work and sickness absence management, with more time with patients and an ability to book follow ups. As health educators, advisors and a coaching advocate, they may be able to provide behavioural change and be effective in challenging the myths that permeate society about the virtues of rest and perils of work. Communication, emotional intelligence, and coaching skills are of valuable use for this role, which is traditionally seen as outside the ‘therapeutic’ scope of practice. If work is to be seen as a health outcome, this is much needed.

Currently, there is no state provision of Occupational Health in the UK, despite its pre-dating the NHS, when factory workers were physically suffering during the industrial revolution. Until it is, FCPs may be able to take on the mantle and have workfocussed discussions with working age adults to prevent avoidable sickness absence. The stressors of 21^st century living are radically different to the traditional ‘disease model’ of illness of the past. Demographics, better living conditions, safer jobs and improved medical care means that individuals are living longer than ever before, but with more co-morbidity and disability. Helping to keep people in work to the greatest possible extent despite their health problems, to reduce costs to employers and the state, and to maximise tax revenues for the exchequer is becoming an urgent social policy objective. FCPs as rehabilitation experts understand how injury and illness can affect individuals with common health problems and likely have the skills and knowledge to consider the support needed to return to normal levels of function in work. Common health problems within the work environment are best managed through a pragmatic human approach that is empowering and consultative rather than a biomedical approach that is inefficient, transactional, and disempowering for individuals.