Australian Perspectives on the GPs Role in Return

To Work: Results of Recent Research

Danielle Mazza1, Bianca Brijnath1, Agnieszka Kosny2, Nabita Singh1, Rasa
Ruseckaite3 and Alex Collie2,3,
1Department

of General Practice,
2Department of Epidemiology and Preventive Medicine,
3 Institute for Safety Compensation and Recovery Research

Background
Meaningful, safe and sustainable work is good for health
Work is the best medicine the AFOEM Statement (>150 signatories)
With almost 96% of injured worker claims originating in the general practice
setting, GPs are the key gatekeeper
Few available studies on the role of healthcare providers in facilitating RTW
and no Australian studies explicitly focusing on the role of GPs in facilitating
RTW.
International data shows GPs encounter a number of barriers to facilitating
RTW.

Aim
To provide an understanding of the GPs role in facilitating
RTW and the barriers encountered in this process.
Study was funded by WorkSafe Victoria and the Transport
Accident Commission.

Mixed methods
Qualitative

Quantitative

Sept-Dec 12

Compensation Research
Database WorkSafe Victoria

93 interviews:
25 GPs, 17 injured
persons, 25
employers and 26
Compensation
agents

GP claims certificates
(~125,000 injured
persons; ~10,000
GPs)

Data thematically analysed

Jan03 - Dec10

Qualitative sample
Group (n)

Mean age (SD)

Gender (n)

Mean years of experience in

current job role (SD)

GPs (25)

52 yrs (10.2)

Male = 72% (18)

Female = 28% (7)

24 yrs (11.8)

Employers (EMP) (25)

45 yrs (11.8)

Male = 36% (9)

Female = 64% (16)

9 yrs (6.5)

Male = 15% (4)

Female = 85% (22)

7 yrs (5.7)

Compensation agents (CS) (26) 34 yrs (9.4)

Injured persons (17)

Mean Age (SD)
Gender (n)

48yrs (13.7)
Men = 71% (12)
Women = 29% (5)
Primary injury type (n)
Musculoskeletal = 71% (12)
MHC = 18% (3)
Both = 12% (2)
Development of secondary Yes = 67% (8)
MHC in 12 MSK claims (n) No = 33% (4)
Clients back at work (n)
Yes = 47% (8)
No = 53% (9)
Time since injury (n)
3 - 6months = 29% (5)
6 - 9months = 0
> 9months = 71% (12)

Quantitative sample
Injured persons
Gender
(M/F)
Condition
Fractures

8,668/3,434
(71.6/28.4)

Mean
Numb
(SD) age er (%)
in years at
onset

Rate,
95%CI

12,102
(100)

0.83
[0.810.85]
3.45
[3.413.47]
1.34
[1.321.36]
1.40
[1.381.42]
0.87
[0.850.88]
0.67
[0.650.68]
8.57
[8.528.62]

40.9
(13.1)

MSK injuries
and diseases

31,490/18,5
42.8
62
(11.5)
(62.9/37.1)
Back pain and 14,835/4,63
38.3
strain
2
(13.2)
(76.2/23.8)
Other
12,831/7,55
traumatic
7
40.8 (11.6)
injuries
(62.9/37.1)
Mental health
5,416/7,247
43.4
conditions
(42.8/57.2)
(10.3)
Other
diseases
Total

7,730/2,022
(79.3/20.7)

Total certificates

44.2
(11.5)

50,052
(100)
19,467
(100)
20,388
(100)
12,663
(100)
9,752
(100)

124,42
80,970/43,4
4
54
41.8 (11.9)
(100)
(65.1/34.9)

Unfit for work

certificates
Number
Rate,
(%)
95%CI

9,838
(81.3)
34,055
(68.0)
15,401
(79.1)
15,816
(77.6)
11,911
(94.1)
5,172
(53.0)
92,193
(74.1)

0.68
[0.660.69]
2.35
[2.322.37]
1.06
[1.041.07]
1.09
[1.071.10]
0.82
[0.800.84]
0.36
[0.340.37]
6.35
[6.316.39]

Alternate duties
certificates
Numb
Rate,
er (%)
95%CI

2,051
(16.9)
14,134
(28.2)
3,414
(17.5)
4,218
(20.7)
610
(4.8)
3,889
(39.9)
28,316
(22.8)

0.14
[0.130.15]
0.97
[0.950.99]
0.24
[0.220.25]
0.29
[0.280.30]
0.04
[0.0380.045]
0.27
[0.250.28]
1.95
[1.921.97]

Fit for work

certificates
Numbe
Rate,
r (%)
95%CI

213
(1.8)
1,863
(3.7)
652
(3.3)
354
(1.7)
142
(1.1)
691
(7.1)
3,915
(3.1)

0.01
[0.00120.0016]
0.13
[0.12-0.14]
0.04
[0.00410.0048]
0.02
[0.00210.0027]
0.01
[0.00080.0011]
0.05
[0.0040.0051]
0.27
[0.26-0.28]

Key themes from the qualitative and quantitative

research
1. Differing views about the role of the GP
2. GP certification practices: what is actually happening?
3. The added complexity and burden of mental health claims
4. Key barriers and enablers for GPs to facilitate RTW
5. Issues with the certificate of capacity

Differing views about the role of the GP

GPs are considered the key gatekeeper for facilitating injured worker
RTW by all four stakeholder groups.
However there is a dissonance between the various groups
understanding of the GP role:
I see that Im an advocate for the patient and Im also basically
mostly trying to concentrate on treating their actual medical problem or
the injury (GP#20, f, 47yo, 21 ye).

I would like to see them [GPs] empowered to have a bit more

confidence to actually have some stronger conversations with their
clients around RTW (CS17,f,26yo,2ye).

GPs certification practices: What is actually

happening?

GPs certification practices: What is actually

happening?
124,424 initial medical certificates issued by GPs:
74.1% unfit for work
22.8% alternative duties

UFW certificates issued to:

94.1% with mental health conditions

81.3% with fractures
79.1% with other traumatic injuries
77.6% with back pain and strains
68.0% with musculoskeletal conditions
53.0% with other diseases.

Alternative-duties certificates were significantly longer in duration than

UFW certificates.

GPs certification practices: What is actually

happening?
Dissonance about the GPs role in certification between the stakeholder
groups.
The heart-sink patients are patients the WorkCover ones that make
us all shudder theres all this conflict between the insurance company
itself, the employer, the patient [and] we are stuck in the middle. (GP#19,
f, 37yo, 13ye).
Poor communication between stakeholders
Allegations of patient malingering and provider over-servicing.
The patients social circumstances
Relationship between the employer and the injured person
Age (older workers less likely to RTW)
Availability of sick leave
Childcare responsibilities at home
Mazza et al. In prep. Br J. Gen Prac

The added complexity and burden of mental

health claims

Mental Health Claims Management and Return to Work:

Qualitative Insights from Melbourne, Australia
Bianca Brijnath1*, Danielle Mazza1, Nabita Singh1, Agnieszka Kosny2, Rasa Ruseckaite3 and
Alex Collie2,3
J Occup Rehab
doi: 10.1007/s10926-014-9506-9
Accepted 5 March 2014

The added complexity and burden of mental

health claims
GP certification behaviour has changed over time:
Increase in Unfit for Work (UFW) certificates mainly for mental health
condition claims.
Women are the main recipients of UFW certificates for mental health
condition claims.
Certified duration of time off work for female claimants increasing over time

The added complexity and burden of mental

health claims
Assessment & Diagnostic difficulties: The most difficult part of a stress claim is
working out the validity of it to start with, whether work is a contributing or significant
factor (EMP5, f,53 yo,7ye).
Conflicting medical opinions: ...the doctors being the advocate for the worker, you got
the other side of the coin with independent medical examiners being branded
insurance doctors saying the other thing (CS#18, m, 61yo, 4ye).
Stigma: I felt guilty. I felt as if, I was questioning myself whether I was putting it all on,
whether it was for real, whether you know maybe I should be back at work (IP#10, f,
61yo).
MH as a secondary illness: If youve got injury where pain lasts for a long [time], after
a while the brain does all sorts of funny things to that and some of the psychological
stuff comes in (GP#25, m, 50yo, 25ye).
Complex management: Whilst a fractured leg might heal in six weeks, some sort of
PTSD or depression could take years and years to heal so its very, very, very slow
(CS#14, f, 29yo, 3ye).

Key barriers for GPs to facilitate RTW

Health system barriers
Finding specialists for referral

Compensation system barriers

GPs lack understanding of how the
system operates

Clinician refusal to treat

High turnover of compensation agents
Conflicting medical opinions
Doctor shopping

Delay in approving payment for

treatment = delay in RTW
GPs feel they are not adequately
renumerated for time and effort

Kosny et al. In prep. Policy and Practice in Health & Safety

Singh et al. submitted. JOEM.
Brijnath et al. submitted. BMJ.

Key enablers for GPs to facilitate RTW

GP education and training:
Mental health claims assessment and management
Clinical management of chronic pain
GP registrars to be educated about Work Cover and the health benefits of
return to work
It wouldnt hurt us to occasionally go to a meeting bringing us up to speed on work
cover legislation. I think the more confident you are in handling the whole system,
the more confident you are ringing up an employer and talking about it if you know
where you stand. (GP1, m,62yo, 40ye)

Injured person motivation and preparedness to RTW

Employer-employee relations
Ongoing communication
Provision of alternative/modified duties
Show of empathy and support

Issues with the Certificate of Capacity

Primary method of communication
GPs unclear about what precisely
the form wanted from them
Compensation agents and
employers complained that the
certificate of capacity needed to
promote a stronger RTW focus
Electronically completed and
integrated into online and realtime systems to enable consistent
and coordinated communication

Discussion
The role of the GP in facilitating RTW is recognised as critical by all parties.
Need to change current certification practice because:
Increasing number of certificates being issued and for longer durations of
time.
Most certificates issued are UFW and workers with mental health claims are
most likely to be certified as unfit.
Main barriers include:
Lack of a common definition on the GPs role in RTW
GPs reliance only on injured workers feedback on capacity to work
Lack of availability of alternative/modified duties
Age and social circumstances of the injured worker and their family
Poor communication between GPs, employers and compensation agents
High administrative burden on GPs from compensation system and low
remuneration of time and effort
Delayed payments, difficulty in referrals and conflicting medical opinions.

Discussion
Overcoming the barriers:
Specific and targeted education and training for GPs on how the
compensation system works, the health benefits of RTW, pain
management and MHC claims assessment and management.
Development of a consensus on GPs role in RTW
Guideline development on diagnosis and management of mental health
claims
Further research:
Implementation research to put in place guideline recommendations
Longitudinal cohort analysis to better understand the relationship
between GPs recommendations and patient outcomes.

Conclusions
First study of its type and size in Australia and internationally. Built capacity
and collaboration in general practice-compensation injury.
WSV and TAC have been highly responsive to study findings:
Redesign of certificate of capacity
Health Benefits of Safe Work Program
GP education and training
Our team has forged linked with other state and national compensation
authorities and key stakeholders (e.g. ComCare; Queensland MAIC; RACGP)
Looking to build on the research: weve now established the baseline, the next
step is to develop the interventions in particular areas (e.g. guideline
development and evaluation for mental health claims).