Abstract

Background The post-operative advice given to patients by health care practitioners regarding return to work and return to driving may have an impact upon their absence duration. The only guidance that is readily available to assist health care practitioners give this advice is provided by the Department of Work and Pensions (DWP).

Aims To identify what advice local consultant surgeons, occupational physicians and general practitioners give to patients about return to work and driving, following benign abdominal hysterectomy (BAH) and Birmingham hip resurfacing (BHR). To explore health care practitioners' awareness of the DWP evidence-based return to work guidelines.

Method A questionnaire was administered to 216 health care practitioners, asking them about the advice they would give to patients undergoing BAH or BHR, regarding return to driving and return to work.

Results Fifty-eight per cent of all health care practitioners that responded were unaware of the DWP evidence-based guidance. Seventy-four per cent of occupational physicians were aware of this guidance but only 32% of general practitioners and 0% of hospital specialists. The advice given regarding expected duration of sickness absence was very variable, ranging between 2 weeks and >12 weeks for both BAH and BHR procedures. Twenty-one different operative ‘patient information sheets’ were examined and these included only very brief and very general advice about return to work.

Conclusion National guidance on post-operative return to work advice could be beneficial. The guidance should be supported by health care practitioners and provide advice about normal ranges of time to return to driving and to return to work.

Introduction

The UK Department of Work and Pensions (DWP) has produced evidence-based return to work guidance for some surgical procedures [1]; however, the awareness and use of these guidelines is unknown.

Ratzon et al. [2] found that surgeons' post-operative advice varies widely and has a direct influence on how long patients are absent from work following surgery. This is similar to our own experiences when studying patients who had undergone benign abdominal hysterectomy (BAH) and Birmingham hip resurfacing (BHR) procedures [3].

Lack of clarity regarding the likely length of absence following surgery can be an obstacle for employers and employee's wishing to undertake earlier, graded, post-operative return to work programmes. We therefore explored what advice is currently being given to patients by health care practitioners in respect of two common surgical procedures.

Methods

This study was undertaken as part of a larger research programme looking at return to work times in patients who had undergone BAH or BHR surgery during 2004/05. Ethical approval had been obtained from the relevant ethics and research committees. A questionnaire was devised to explore what advice health care practitioners were giving to their patients in respect of their likely absence from work and their ability to return to driving. The health care practitioner was also asked about awareness of the DWP evidence-based guidance on return to work times following surgery [1].

Questionnaires were distributed to occupational physicians attending two national conferences held in March/April 2005, one organized by the Association of National Health Service (NHS) Occupational Physicians and the other by the Association of Local Authority Medical Advisors. One hundred questionnaires were handed out at each of these meetings, as well as to 92 general practitioners who attended a protected learning event in Birmingham. The questionnaire was also distributed to 11 consultant obstetricians and gynaecologists within Sandwell and West Birmingham NHS Trust, and to 13 consultant orthopaedic surgeons at the Birmingham Orthopaedic Hospital.

Twenty-one ‘patient information sheets’ relating to BAH or BHR were identified via the internet and were examined for specific advice regarding return to driving and return to work. These included 10 hysterectomy and 11 hip surgery ‘advice sheets’.

Results

One hundred completed questionnaires were collected from 216 distributed giving a total response rate of 46%. All consultants responded, 38% of occupational physicians and 41% of GPs.

There were 87 responses relating to BAH procedures. Of these, 38 (44%) were occupational physicians, 38 (44%) general practitioners and 11 (13%) consultant gynaecologists.

Seventy-four respondents (86%) stated that patients should be able to return to driving within 6 weeks following BAH (range 1–10 weeks, mean 6 weeks, SD 2 weeks), see Table 1.

Table 1.

Advised return to work times following BAH

BAH 
Return to work Office duties M + H 
 n n 
Within 3 weeks 
Between 5–6 weeks 46 53 18 21 
Between 7–8 weeks 21 24 17 20 
Between 9–12 weeks 14 16 40 46 
Over 12 weeks 
Other 
Do not know 
BAH 
Return to work Office duties M + H 
 n n 
Within 3 weeks 
Between 5–6 weeks 46 53 18 21 
Between 7–8 weeks 21 24 17 20 
Between 9–12 weeks 14 16 40 46 
Over 12 weeks 
Other 
Do not know 

The range of times within which health care practitioners advised patients to return to both office type work and moving and handling (M + H) tasks was variable (Table 1). Fifty-six per cent of all respondents felt that the patient should be able to return to work within 6 weeks, and 80% felt they should be able to return within 8 weeks of surgery. Of the consultant responses, 6 (55%) gynaecologists advised a return to office work within 6 weeks, 4 (36%) within 8 weeks and 1 (9%) within 10 weeks. In respect of M + H duties, 4 (36%) of consultants advised a return between 4 and 9 weeks and 6 (55%) a return within 10–12 weeks. One consultant (9%) advised a return to M + H duties at >12 weeks.

Ten hysterectomy ‘patient information’ leaflets were examined for return to work and return to driving advice. Nine patient information leaflets advised that patients could return to driving 4 weeks after abdominal hysterectomy. One advised that patients should be, ‘Able to stamp your feet hard’, and two advised that patients should be able to do an emergency stop and consult their vehicle insurers before returning to driving. One information sheet offered no advice regarding return to driving.

There were 89 respondents to the questions relating to hip replacement (BHR). Thirty-eight (43%) were occupational physicians, 38 (43%) general practitioners and 13 (15%) consultant orthopaedic surgeons.

Forty-five (51%) of the respondents considered that patients should be able to return to driving within 6 weeks of BHR (range 2–6 weeks, mean 5 weeks, SD 1 week), see Table 2. Nineteen (21%) advised a return to driving within 8 weeks. Nineteen (21%) expected patients to take longer than 8 weeks and three (4%) reported ‘other’ unspecified periods.

Table 2.

Advised return to work times following BHR

BHR 
Return to work Office duties M + H 
 n n 
Within 3 weeks 
Between 4–6 weeks 35 39 16 18 
Between 7–8 weeks 18 20 11 12 
Between 9–12 weeks 18 20 37 42 
Over 12 weeks 17 19 
Do not know 
Other 
BHR 
Return to work Office duties M + H 
 n n 
Within 3 weeks 
Between 4–6 weeks 35 39 16 18 
Between 7–8 weeks 18 20 11 12 
Between 9–12 weeks 18 20 37 42 
Over 12 weeks 17 19 
Do not know 
Other 

The range of times within which all health care practitioners advised patients to return to office type work and M + H tasks following BHR was variable (Table 2). Thirty-eight (43%) of all participants indicated that they would advise a return to office work within 6 weeks of surgery and 74 (73%) to M + H tasks within 12 weeks of surgery. These combined results were similar to those of the orthopaedic consultants alone, of whom six (46%) expected their patients to return to office work within 6 weeks of surgery, and eight (62%) to M + H tasks within 12 weeks of surgery. Three other consultant orthopaedic surgeons (23%) advocated a return to work within other periods of time, including a return to desk work within 2.5 weeks, and longer than 12 weeks if other joint problems were present.

Opinions among the health care practitioners regarding the ability of a patient to return to heavy physical labour following hip surgery were inconsistent (Table 3). Although 13 (14%) would advise patients that they could return to such work, 66 respondents (74%) would expect them to return only occasionally. This was also reflected in the response from orthopaedic surgeons, where 10 (77%) would only occasionally advise patients to return to heavy physical work.

Table 3.

Health care practitioners' expectation of patients return to heavy physical labour following hip surgery

Options GPs OHPs Consultants All, n = 89 % All 
 n %/38 n %/38 n %/13   
Usually 16 16 13 15 
Sometimes 18 47 16 42 39 39 44 
Usually not 10 26 15 39 45 31 35 
Other 
No response 11 
Options GPs OHPs Consultants All, n = 89 % All 
 n %/38 n %/38 n %/13   
Usually 16 16 13 15 
Sometimes 18 47 16 42 39 39 44 
Usually not 10 26 15 39 45 31 35 
Other 
No response 11 

OHPs, occupational health physicians.

Eleven patient information leaflets (hip replacement/resurfacing) were examined. Advice regarding driving was given in four instances. Three suggested return within 5–6 weeks post-operatively, while one advocated that patients refrain from driving for 3 months. One advised that the patient should feel confident to do an emergency stop and that the patient's vehicle insurer be informed.

Specific return to work times were stated in only four instances (two of which contained advice regarding driving). Three advised return to work within 6–8 weeks of surgery without stipulating any limitations on the type of work other than general activities to be avoided such as squatting, twisting or prolonged standing. One suggested return to office work after 6 weeks but if work involved prolonged standing, the patient should refrain from work for 3 months.

The awareness of respondents to the DWP evidence-based post-operative guidance [4] is outlined in Table 4. Fifty-eight (56%) of all respondents were unaware of this guidance, although it was evident that none of the consultants were aware of it.

Table 4.

Health care practitioners awareness of DWP guidance

Options GPs (38) OHPs (38) Cons. G. (11) Cons. O.S. (13) All 100 All% 
 n n n n   
Aware 12 32 28 74 40 40 
Unaware 26 68 10 26 11 100 11 85 58 58 
No response 15 
Total 38 100 38 100 11 100 13 100 100 100 
Options GPs (38) OHPs (38) Cons. G. (11) Cons. O.S. (13) All 100 All% 
 n n n n   
Aware 12 32 28 74 40 40 
Unaware 26 68 10 26 11 100 11 85 58 58 
No response 15 
Total 38 100 38 100 11 100 13 100 100 100 

Cons. G., consultant gynaecologist; Cons. O.S., consultant orthopaedic surgeon.

Discussion

Our study found large variation in the advice being given to patients about when they can return to driving and return to work. These findings reflect what we found during our more detailed retrospective study of patients who had undergone these procedures. [3] While it is acknowledged that the sample was small, we believe that the responses give an indication of the variation in advice being given. The orthopaedic and gynaecological specialists all worked within two NHS Trusts, so it may be expected that their views would be more consistent than a larger number of consultants working within more NHS Trusts. The response rate suggested an interest in this topic; however, we believe that it would be beneficial to repeat this survey on a wider basis and if possible in conjunction with the relevant Royal College.

Health care practitioners and particularly consultants were unaware of the DWP evidence-based guidance on return to work times. It is uncertain whether knowledge of this information would modify their current advice or whether the consultants actually agree with the information within this guidance. (The guidance did not include information for BHR.) It is likely that patients' recovery time will be guided by the advice given by their specialists or general practitioner. If this is unduly conservative or non-specific, then it is likely that return to driving and return to work times will be longer than necessary. This was reflected within our other study where it was shown that the duration of absence was generally consistent with whatever advice the patient was given by their health care adviser, although the return to work time was shorter where the patient felt an ‘urgency’ to return to work. [3]

Post-operative advice regarding return to work and driving may not be perceived as a priority for many surgeons. As a result, patients may remain uncertain about what to expect. Where advice is given, it is likely to be very conservative. Dassinger et al. [4] found that more pro-active communication about return to work can result in a 60% improvement in return to work times, therefore more awareness and pro-active advice by consultants may significantly impact upon their patient's rehabilitation and recovery times. Lack of clarity as to likely absence duration can also provide an obstacle for employers and employees who are keen and willing to establish earlier rehabilitation programmes but would not wish to go against the advice of health care advisors.

No definitive guidance relating to return to work following hip surgery exists within the UK. American evidence-based guidance, the Official Disability Guidance [5], gives advice on return to work following hip replacement and suggests that patients could return to clerical type or modified duties including manual/standing work within 6–12 weeks. Hip resurfacing is regarded as a less invasive procedure which might therefore have a shorter recovery period.

Patient information leaflets that were examined only made generalized comments regarding expected absence duration and were usually contained within a single sentence among a plethora of other information.

Many patients have to drive to work and therefore any advice in respect of ability to drive is likely to impact both on the patient's duration of recovery and on their ability to return to work. Both health care workers and patients are uncertain as to the criteria that should be used to determine ‘fitness to drive’ following any form of surgery. It could be argued that the patient should be able to undertake any emergency procedure safely and without danger to themselves or the public. It was the experience of one of the authors that this was possible 2.5 weeks post-BHR surgery, yet the standard advice by the specialist team had been not to return to driving for 4–6 weeks post-operatively. Communications with the Driver and Vehicle Licensing Agency, insurer and the general practitioner all resulted in different opinions regarding when it would be reasonable to return to driving and for the majority of patients would result in a very conservative approach. In respect of hip surgery, the advice may be dependent upon which leg was operated on and whether the car is ‘automatic’ or not. Such variation in advice can take time to explain and may be why more generalized conservative advice is given. This type of information could possibly be explained in more detail through written information leaflets which the patient could then discuss with their general practitioner.

Key points

  • The time that patients are advised to refrain from driving and return to work following BAH and BHR is extremely variable.

  • There was little or no awareness of evidence-based guidelines on BAH return to work times by hospital consultants and general practitioners.

  • Availability of standardized guidance similar to that provided within the USA Official Disability Guidance would assist health care practitioners and employers in their efforts to facilitate more consistent and timely return to work programmes for individuals who have undergone surgery.

Conflicts of interest

None declared.

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