Editorials |
Health, work and the general practitioner
A substantial number of general practitioners (GPs) practice occupational medicine in the UK, working on a sessional basis in addition to their primary care commitments [1]. Many of these GPs hold the Diploma of the Faculty of Occupational Medicine. In addition to the work of these GPs with a special interest, issues relating to work and sickness absence form a significant part of the workload in general practice [2]. Dame Carol Black's report, ‘Working for a healthier tomorrow’, raises concern about the lack of understanding of the relationship between work and a patient's health, and the omission of this evidence from professional training [3]. The report suggests that the work-related advice given to patients by health care professionals can be naturally cautious and may not be in the best interests of the patient for the long term. There is, therefore, an urgent need for research to help health professionals, and in particular, GPs to understand the issues involved in work-related ill-health and in sickness absence certification.Much of the existing work on sickness absence has been carried out in Scandinavia [4–6]. Although the Scandinavian system of primary care differs from that in the UK, the principles of sickness certification are similar and the factors associated with duration of sickness absence appear to be consistent in UK and Scandinavian studies [7]. The factors associated with the development of long-term incapacity are social deprivation, increasing age and the diagnosis at presentation. Mild mental disorders account for the highest proportion of sickness absence in the UK, while musculoskeletal conditions appear to remain the largest factor in Scandinavia [6]. There is concern about the apparent increasing incidence of sickness absence due to mental ill-health in Scandinavia [5].
The launch of THOR-GP, a national network of GPs interested in occupational health and reporting cases of work-related ill-health in 2005, enabled us to gain insight into work-related ill-health as seen in a general practice setting. This includes information relating to any certified sickness absence associated with a reported case. A study of this information suggests that GPs tend to underestimate the duration of medically certified sickness absence resulting from work-related illness. Half of all cases reported by 
300 GPs to THOR-GP in 2006 involved medical certification for absence, producing a total of >23 000 days of certified work-related sickness absence. As the data period for THOR-GP increases, further analysis of this information in its own right and with comparisons to reports from specialists and occupational physicians reporting to THOR, as well as with ‘all cause’ sickness absence, will strengthen our knowledge base of past and current work-related ill-health in the UK. A study of Norwegian GPs found that their predictions of return to work were accurate for short-term absences but much less so for long-term absence. The doctors’ ability to predict return to work in short-term absence was lowest for those associated with mental ill-health and in cases of long-term absence the probability of accurate prediction was lowest for musculoskeletal disorders and injuries [4].
A key message from THOR and THOR-GP is that there is significant variation in the diagnostic categories reported across industrial sectors (Figure 1) [8]. Larger proportions of work-related mental ill-health cases derive from education, health & social care and financial intermediation compared to other sectors, while a higher proportion of work-related musculoskeletal disorders is found in the construction industry. Cases of work-related disease reported in the hair and beauty sector are predominantly skin diagnoses.
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An example of the ability of THOR and THOR-GP to demonstrate trends in the incidence of work-related ill-health is demonstrated by the incidence of work-related stress and mental illness reported by occupational physicians to OPRA. The estimated annual increase in the incidence of these conditions was
13% in the 5 years following 1999 [9]. These results will be reported in full shortly. NICE guidelines for the treatment of anxiety and depression first published in 2004 recommend that the majority of patients are treated within primary care [10]. It is therefore important that data from general practice are used to complement and underpin those from specialist services relating to mental ill-health. THOR-GP data confirm the findings of other studies by showing that mental ill-health cases were more likely to be associated with medical certification and were associated with longer periods of sickness absence than other work-related ill-health diagnoses [8]. THOR-GP will enable the analysis of cases of work-related ill-health by other factors such as the precipitating events attributed to the reported cases of mental ill-health and tasks associated with musculoskeletal disorders [11]. For example, psychological cases may be attributed to ‘workload’ or to ‘interpersonal difficulties’ such as ‘difficulties with managers/co-workers’ or ‘bullying’. The scheme will also permit analysis of the varying incidence of reported work-related disease according to age, gender, occupation and industry. GPs are in the unique position not only to report on the sickness absence associated with the work-related ill-health but also to give information on referrals to other health practitioners.
‘Working for a healthier tomorrow’ calls for the integration of occupational health services into the NHS and for a network of GPs interested in health and work to be a source of growing expertise at a regional and local level [3]. THOR-GP provides such a network of some 300 GPs reporting cases of occupational ill-health seen in general practice and participating in an Internet forum for the discussion of work-related problems in primary care. The data from THOR-GP will enable, for the first time, assessment of the problem of work-related ill-health at the primary care level where the major part of the burden of diagnosis, management and sickness certification falls on GPs. Thus, an appropriate balance of information can be maintained with respect to the effect of work on health and vice versa. The THOR-GP network also provides an opportunity to help equip GPs for the task by the provision of educational resources in occupational medicine [12].
1 Occupational and Environmental Health Research Group, Faculty of Medical and Human Sciences, The University of Manchester, Manchester M13 9PL, UK
2 Central Manchester and Manchester Children's University Hospitals NHS Trust
e-mail: kevanthorley{at}aol.com
References
- Smith NAL. Occupational medicine and the general practitioner. Occup Med (Lond) (2005) 55:77–78.[CrossRef][Medline]
- Sawney P. Current issues in fitness for work certification. Br J Gen Pract (2002) 52:217–222.[Web of Science][Medline]
- Black C. Working for a Healthier Tomorrow. Report to the Secretary of State for Health and the Secretary of State for Work and Pensions (2008) London: TSO.
- Reiso H, Gulbrandseb P, Brage S. Doctors' prediction of certified sickness absence. Fam Pract (2004) 212:192–197.
- Nystuen P, Hagen KB, Herrin J. Mental health problems as a cause of long-term sick leave in the Norwegian workforce. Scand J Public Health (2001) 29:175–182.
[Abstract/Free Full Text] - Lotters F, Burdorf A. Prognostic factors for duration of sickness absence due to musculoskeletal disorders. Clin J Pain (2006) 22:212–221.[CrossRef][Web of Science][Medline]
- Shiels C, Gabbay MB. Patient, clinican and general practice factors in long-term certified sickness. Scand J Public Health (2007) 35:250–256.
[Abstract/Free Full Text] - Hussey L, Turner S, Thorley KJ, MacNamee R, Agius R. Work-related ill-health and sickness absence in general practice, as reported to a UK-wide surveillance scheme. Br J Gen Pract. (in press).
- McNamee R, Carder M, Chen Y, Agius R. Time Trends in the Incidence of Work-Related Disease in the UK, 1996–2004: Estimation from ODIN/THOR Surveillance Data. Research Report to the Health and Safety Executive, 2006. http://www.hse.gov.uk/statistics/pdf/trendsinthor.pdf (April 2008, date last accessed).
- CG23 Depression: NICE Guideline (Amended) (2007).
- Cherry N, Chen Y, McDonald C. Reported incidence and precipitating factors of work-related stress and mental ill-health in the United Kingdom (1996–2001). Occup Med (Lond) (2006) 56:414–421.[CrossRef][Medline]
- Thorley KJ, Turner S, Hussey L, Zarin N, Agius R. CPD for GPs using the THOR-GP website. Occup Med (Lond) (2007) 57:575–580.[CrossRef][Medline]
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