Return to work 

 

 This guidance has been developed by a Practitioner Health clinician and is aimed at helping you a practitioner-patient prepare for being back in the workplace after a prolonged absence, and assist in considering how you might handle questions and protect yourself from facing a similar incident. Most clinicians who need to take a period of sickness absence, or who are on sickness leave when they access Practitioner Health, do return to work following treatment and recovery. Upwards of 80% of those who were not working when they accessed the service return to work, including some who had been not working due to mental illness for a number of years.

PH differs from Occupational Health

  • At PH we are not an Occupational Health service. However we recognise that not all patients who are off work due to illness may have access to Occupational Health. PH clinicians can often discuss with the practitioner-patient the timing of the return to work and the return to work plan from the patient’s perspective. This could include consideration of what to tell colleagues about your illness, making arrangements for attending ongoing therapy appointments or how you might deal with any triggers in the workplace that may affect your mental wellbeing.
  • The role of Occupational Health is to view the return to work and associated plan from both patient’s and employer’s perspective, including considering any reasonable adjustments that may be required that will enable you to continue in your role.

When to ask for an independent Occupational Health review

Sometimes it may be helpful to get an independent Occupation Health review. This is particularly useful if your organisation/employer does not have access to its own service. The review can provide advice  around your fitness to return and the timing of that return, for example if:

  • Your organisation/employer is encouraging you to come back before you feel ready.
  • You may want to go back before your organisation/employer or even your PH clinician thinks you are ready.

Your organisation/employer may agree to fund this Occupational Health review. For GPs on the Performers List this may be funded by the local area team.

 

What will be taken into consideration when deciding if you are ready to return to work?

If you have been off work due to a mental health issue, the most important thing that you, your PH clinician and your organisation/employer will need to consider is that you are now recovered enough to pick up some, or all of your duties and that it will be safe for you and your patients to do so.

There will be consideration of:
  • Presenting illness/ cause for time off and the response to treatment
  • Any workplace triggers (e.g. Partnership or team difficulties or pending issues)
  • Full understanding of roles, duties in roles and weekly timetable (to inform phased return)
  • Liaison with Occupational Health or any other health professionals involved with your care to gather information about your fitness to return
  • Anything to learn from a previous experience of return to work plan. Did it go smoothly or not?
  • Any previous episodes of sickness absence.
  • The aim is to help the practitioner-patient to think about a suitable phased return to work plan (if necessary) and over what period. Sometimes it can be helpful to add in additional duties/roles gradually with on call/duty sessions usually the last thing to add in.

Timing of return

  • This should be neither too soon, which would decrease the chance of success if the doctor patient is not sufficiently recovered, or too long off work.
  • The longer a clinician is away from the workplace due to ill health the increased likelihood that you will start to lose confidence in your own ability to manage in the role. Time off also allows increased time for rumination and worry whilst off sick.

Value of activity scheduling

  • Following a longer period of sick leave it can sometimes be helpful to start back on a part time basis, building up to full time work.
  • Many patients find it useful to start building up a full time (9am to 5pm) schedule of non-work activities prior to return to work to build up the stamina, a sense of mastery and to improve self-confidence
  • Remember to include a mixture of productive and enjoyable activities (which can be rated out of 10 in a diary for productivity and enjoyment)
  • Start with one activity per day and build up gradually.

Top Tip: Good to include some activities which will be feasible to continue alongside work for replenishment and relaxation once back at work

Psychological aspects pre return to work

One of the most common issues for a clinician returning to work after a lengthy absence can be psychological aspects associated with being back in the workplace.

  • It is very common to experience a marked increase in anxiety once the decision has been made to agree a return to work date.
  • This anticipatory anxiety follows a typical curve increasing in the days preceding the return and then easing once back in the workplace and getting on with daily tasks.
  • Rehearsal is also helpful. Consider how you might answer questions from colleagues about reasons for absence (e.g. on return after an inpatient detoxification from alcohol or drugs)
  • You may choose to share different levels of information with your senior colleagues and supervisors, than you do with your practice or hospital team and with your patients.
  • The aim is for the practitioner-patient to share enough information to have appropriate support on return to work and to maintain the trust of their close colleagues, whilst reserving the right to privacy about your clinical details.

This section deals with the health and psychological aspects of returning to work after a prolonged absence. However, you may also have had an enforced absence due to suspension or erasure following a complaint or investigation.If this is the case, you may have additional considerations around returning to the workplace and we hope some of these additional documents may help.

  1. Disclosure  -  Guidance about how to navigate applying for a job/returning to a clinical role following an investigation, suspension or exclusion from the regulator register.
Distinction between performance issues and health fitness to work
  • If performance issues then NHS England and/or GMC may be involved 
  • For example NHS England may be involved when concerns have been raised about the doctor patient’s note keeping leading to voluntary undertakings including clinical supervision for a set period
  • A National Clinical Assessment Service (NCAS) assessment may sometimes be commissioned to assess an individual’s competency but this is expensive. www.ncas.nhs.uk.
Health fitness to work
  • Severe and enduring mental health problems require special considerations. Certain guidance from the GMC applies.
  • There is a high successful return to work rate for doctor patients attending  PHP or GP Health. (NB could potentially get a statistic from the 10-year PH report data)
  • Under certain circumstances mental or physical health problems may lead to a decision to stop working
  • For example a doctor patient had a physical neurological condition affecting manual dexterity required for their role. They left work having applied for retirement on medical grounds as they were unable to continue to perform their own role.
Retirement on medical grounds
  • This depends on being assessed (by own GP or Hospital Consultant and not by PH clinician) as having a permanent condition (present for more than a year which has not responded sufficiently to all reasonable treatment options).
  • There are 2 tiers awarded: unable to perform own role (Tier 1) and unable to perform any role (Tier 2).
Income protection
  • Some doctor patients have a private income protection plan which they can claim on after a certain length of time off work as stated in their policy.
  • At PH we may provide a brief summary report with the doctor patient’s consent once they have agreed the draft report. We tend not to grant full access to all PH records due to our confidentiality agreement outlined at the start of treatment. The Insurance company can request a full set of medical records from the doctor patient’s own GP in the usual way (as when PH are not involved).

DBS

We considered what would be the best approach to disclosure when applying for a future job

Action – Ask Hurley Group HR to advise on good approaches they have encountered

Guidance for doctors and other patients of PH about how to navigate applying for a job/returning to a clinical role following an investigation, suspension or exclusion from the regulator register[AM4] 

 

Restoration to the Medical Register

  1. Can apply after five years or more after the date of erasure.
  2. If restoration granted it will be an Unrestricted practice.
  3. Cannot impose conditions or restrict doctor’s practice in any way.
  4. May be asked to work in an Approved practice setting for 12 months.
  5. Doctor should demonstrate following to the Tribunal.
  • Doctor has insight and have dealt with all the issues that led to the erasure.
  • Kept his or her medical knowledge and skills up to date.
  • Safe to restore to the register with unrestricted practice

At the hearing MPTS will consider following points

  1. The circumstances that led to erasure
  2. The reasons given by the previous tribunal (or committee) for the decision to direct erasure.
  3. Whether doctor has any insight into the matters that led to erasure.
  4. What doctor has done since his or her name was erased from the register. (Employment log, Clinical Knowledge log, Reflection log)
  5. The steps doctor has taken to keep his or her medical knowledge and skills up to date and steps he or she has taken to rehabilitate his self or herself professionally and socially.

Five year plan

 a) Employment Log: 

  • Employment Status
  • Place of working & Duties

b) Clinical Knowledge Log:

At least 8 hours of clinical learning each month

  • Reading an article
  • Clinical updates
  • Attending courses
  • Online courses
  • Clinical attachmentsc)

c) Reflection Log:

  • This log is to help address the issues of dishonesty/probity concerns that led to doctor’s erasure.
  • Own reflection on the event and how a doctor has tried to improve his or her actions to prevent such similar incidents from recurring.

Tribunal may adjourn their hearing before reaching a decision on doctors’ application for restoration:

Performance Assessment

  • If the erasure was due to an unacceptably low professional performance describes a standard of an average doctor.
  • When the evidences show that, a doctor has failed to keep his or her medical knowledge and skill up to date and steps he or she has taken to rehabilitate his self or herself professionally and socially (communication skills), which has led to an erasure.
  • The decision to direct a performance assessment is informed by any documentation provided by the doctor in support of the restoration application. Rule 23 (1) (b) would apply in this instance.
  • After a long gap in medical practice.
  • Doctor should pay £6000 plus VAT (must paid in full prior to assessment)
  • Generally, the assessment can take from 6months (in the case of a General Practitioner) to 12 months and beyond (in the case of a specific speciality). This is due to availability of the assessor.

                                                   

 

 

1. What comprises an assessment?

The content of your assessment will depend on your speciality, the nature of your practice and whether you’re currently in work. It may include workplace-based assessment and tests of knowledge and skills.

2. What is a performance assessment?

A performance assessment is an assessment of the standard of your professional performance. Your assessment will be completed by a team of independent assessors.

They’ll provide GMC with a report which will describe your professional performance and give the team’s opinion on your fitness to practice. The assessment will last between one and five days. The content of the assessment will depend on your speciality, the nature of your work, and whether you’re currently in work.

3. When will you be assessed?

It can take several weeks to appoint assessors and set the dates of your assessment. Due to availability of both parties.

4. Who will assess your performance and what information will they be given?

GMC will give you the names of your assessors once they have been appointed. An assessment team usually comprises

  1. A medically qualified team leader.
  2. One or medical assessors.
  3. A lay (non-medical) assessor.

When GMC select the medical assessors, they will consider:

  • Your current or most recent speciality or sub- speciality, and the nature of your work
  • The area of practice to which the concerns relate.
  • Your level or grade
5. How will you be assessed?

Your performance will be judged in up to eight categories based on the content of Good medical practice.

Assessment category

Areas that might be assessed

Maintaining professional performance

Educational activities, keeping up-to-date, knowledge of guidelines and regulations, audit and appraisal.

Assessment

History taking, examination, initial investigations and reaching a diagnosis.

Clinical Management

Providing treatment, advice to patients or referral safety netting, follow up and working within the limits of competence.

Operative / Technical Skills

Carrying out procedures, administering an anaesthetic, slide preparation etc.

Record keeping

Accurate record keeping.

Safety and quality

Protecting patients and acting if patients are at risk (including inadequate care, policies and systems).

Relationships with patients

Communication, information sharing, supporting self-care and treating patients (including carers and relatives) with fairness and respect.

Working with Colleagues

Teamwork, leadership, communication (including written), teaching.

   6. What will your assessment consist of?

Objective Structured Clinical Examination. (OSCE):

All assessors record comments and judgements. The lay assessor will judge your interactions with the role players. The Medical assessors will independently score your performance on a structured marking schedule.

Your total score for each station is compared with that achieved by a reference group. OSCE has 12 stations. 

At each station you will be given a task to perform which may involve

  • Using medical equipment or anatomical models.
  • Interacting with patients or with role players acting as patients, carers or colleagues.
  • A written task.
  • Interpreting investigations results or other information.
Simulated surgery (GPs only):

The test is assessed, and the results are presented in the same way as the OSCE. Additionally, there will be an analysis of the score you achieved in the different domains:

  • Data gathering, technical and assessment skills.
  • Clinical management skills.
  • Interpersonal skills.
 Knowledge Test:
  • Most knowledge tests have between 90 and 120 questions.
  • The paper will contain core questions about professionalisms and the duties of a doctor and clinical questions relevant to your speciality.
  • A time limit will be given, usually between 90 minutes and two hours depending on the number of questions.
  • If you are a GP it is likely that you will sit a Two-Hour Paper, comprising 120 questions.
  • No Negative marking.
7. What happens after the assessment?

After the assessment, the team leader drafts a report. Due to the volume of data gathered, it will take the team at least several weeks to produce their report.

8. Do you need to prepare?

You are being assessed in the job you do, or have done, so there be no need for special preparation. You will be assessed against the standards described in the GMC core guidance, Good medical practice.

9. What support is available?

You may contact the Doctors Support Service at the GMC. 

10. What if a doctor can’t attend the assessment or refuse to cooperate?

Failure to cooperate, to attend all parts of the assessment without good reason, may result in your case being referred to a hearing at the MPTS.

Health Assessment

Adverse physical or mental health which raises a possibility of impairment can be assessed through a GMC health assessment. The assessment involves the doctor attending appointments with two health examiners appointed by the GMC.

Types of behaviour that may suggest that an individual is unwell.

Suicidal thoughts or self-harm

Serious or persistent negative ways of thinking or talking

Anger 

Sever feelings of anxiety

Failure to respond to communication, or excessive frequency of communication.

Tearfulness

Dissociation, unusual ways of thinking

Failure to meet deadlines.

Irritability

Rapid or Severe fluctuations in mood.

Changes in appetite, weight, sleeping patterns

Poor memory, difficulty recalling facts or events.

Pressurized and rapid speech

 

 

In addition, a perceived deterioration in, or lack of knowledge of, English language may be symptomatic of an undiagnosed health condition or the deterioration of a diagnosed health condition.

Health concerns which may impact on doctor’s communication skills includes neurodegenerative disorders and acquired brain injuries from either a traumatic or non-traumatic event.

The presence of doctor’s health appears to have led to involvement in dishonest or criminal activity. (Guidance for MPTS on adjourning to direct an assessment or for further information or reports to be obtained. www.mpts-uk.org,  page 6, para 27 (h).

 Health assessment will be done by GMC, free of charge.

Overview of the health assessment arrangement.

 

Knowledge of English Assessment

Doctor should pay for International English Language Testing System (IELTS) test and the Occupational English Test – medicine profession version (OET). A doctor’s fitness to practice may be found to be impaired by reason of not having the necessary knowledge of English to practice medicine safely. Objective of this assessment is to see a doctor’s ability in;

  • Listening
  • Reading
  • Writing
  • Speaking

GMC will issue the doctor with the details of how to book an English language assessment Information.

Doctor should provide GMC with the details of their assessment results.

After receiving all the appropriate assessment reports the Tribunal will reconvene to deliberate their decision and if the application is successful, the doctor will be restored to the register as soon as possible, following the completion of certain administrative tasks.

If the doctor’s application succeeds, he or she may have to work in an Approved practice setting

Approved Practice Settings are for:

  • A UK or International medical graduate who is new to registration.
  • Restoring any type of registration after significant break in UK practice.
  • Restoring a doctor’s registration and he or she did not revalidate when he or she previously held full registration.
  • No need to work in an approved practice setting if a doctor is from EEA or joining the GP or Specialist register for the first time.

All designated bodies are recognised as being approved practice settings.

A Designated body is a UK organisation that provide doctors with an annual appraisal and helps with their revalidation.  It will also support doctor’s relevant training needs and continuing professional development. A designated body, through its responsible officer (RO), will act on concerns about a doctor’s fitness to practice.

Responsible Officers are the individuals within designated bodies who have overall responsibility for helping a doctor with revalidation ……… evaluating the fitness to practice of all doctors with whom the designated body has prescribed connection and making a recommendation to the GMC regarding revalidation.

The GMC has online tool to help doctors in doubt find their Designated Body.