Successful return to work with chronic pain? Stakeholders' negotiation strategies

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This paper discusses research from both Wainwright et al (2014) and Wainwright et al (2013) which investigated issues and possible ameliorating factors surrounding the sickness certification and return to work processes for chronic pain patients. The paper was presented as part of the ESRC Seminar Series "Sustaining Employee Wellbeing in the 21st Century"

Wainwright et al (2014) abstract:
The UK government is promoting the health benefits of work, in order to change doctors’ and patients’ behaviour and reduce sickness absence. The rationale is that many people ‘off sick’ would have better outcomes by staying at work; but reducing the costs of health care and benefits is also an imperative. Replacement of the ‘sick note’ with the ‘fit note’ and a national educational programme are intended to reduce sickness-certification rates, but how will these initiatives impact on doctor–patient relationships and the existing tension between the doctor as patient advocate and gate-keeper to services and benefits? This tension is particularly acute for problems like chronic pain where diagnosis, prognosis and work capacity can be unclear. We interviewed 13 doctors and 30 chronic pain patients about their experiences of negotiating medical certification for work absence and their views of the new policies. Our findings highlight the limitations of naïve rationalist approaches to judgements of work absence and fitness for work for people with chronic pain. Moral, socio-cultural and practical factors are invoked by doctors and patients to contest decisions, and although both groups support the fit note’s focus on capacity, they doubt it will overcome tensions in the consultation. Doctors value tacit skills of persuasion and negotiation that can change how patients conceptualise their illness and respond to it. Policy-makers increasingly recognise the role of this tacit knowledge and we conclude that sick-listing can be improved by further developing these skills and acknowledging the structural context within which protagonists negotiate sick-listing.

Wainwright et al (2013) abstract:
The sickness certification and return to work (RTW) of people with chronic pain are important health and economic issues for employees, employers, taxpayers and the UK government. The ‘fit note’ and a national educational programme promoting RTW were introduced in 2010 to curb rising rates of sickness absence.
To investigate employers’ and employees’ experiences of managing RTW when someone has taken sick leave for chronic pain, and to explore the perceived efficacy of the fit note.
A qualitative study, comprising semi-structured interviews with employers who had managed sick leave cases and employees who had experienced sick leave for chronic pain. Interviews were recorded, transcribed and the data analysed using constructivist grounded theory principles.
Five themes were elicited. Firstly, frequent enquiry after health status was seen as intrusive by some employees but part of good practice by employers and acknowledging this difference was useful. Secondly, being able to trust employees due to their performance track record was helpful for employers when dealing with complex chronic pain conditions. Thirdly, feeling valued increased employees’ motivation to return to work. Fourthly, guidelines about maintaining contact with absent employees were useful if used flexibly. Finally, both parties valued the fit note for its positive language, interrogative format and biomedical authority.
The fit note was perceived to be helpful if used in combination with other strategies for managing sick leave and RTW for people with chronic pain. These strategies may be applicable to other fluctuating, long-term conditions with medically unexplained elements.
Original languageEnglish
Publication statusUnpublished - 21 Nov 2014


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