Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.37949.656389.EE (Published 09 January 2004) Cite this as: BMJ 2004;328:88
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Editor,
Doctors are agents of social control and get paid accordingly. And
you’d better believe it, because it ain’t about to change.
A cold ain’t a cold until you say it is. A person ain’t fit to drive
until you say they are and nobody ain’t fit to go back to work until you
say they are.
Into all this comes the patient. There are the driven folk, those
without insight, who want you to look under the bonnet, twiddle a few
knobs and send them magically repaired back on their way. These are the
people you encourage to take time off work because it’s all you can do and
often they take no notice.
Then you have the amorphous dispossessed. Those who have to work and
don’t feel up to it; those who experience the drudgery of manual work when
there is depression or pain. Those out of work and under pressure to take
jobs that are even worse than the ones they’ve lost. These people create
the dialogue of uncertainty that is so accurately illustrated in Hussey’s
paper (1). I am reminded of a man who came to do some work on my house, a Polish immigrant who
came here after the second world war and who told me with poker faced
honesty that “I’ve been a plasterer for 30 years and I still don’t like
it”.
In the face of this uncertainty we create terms and phrases that
obfuscate. We write sick notes unthinkingly and inconsistently, doing so
with good grace for those we like and more grudgingly for those who make
us feel angry or uncomfortable.
There is an anarchy in all this that we rather enjoy, but we do so
irresponsibly. In one of the focus groups there was a doctor who had
written nothing in the space provided for diagnostic detail and boasted
that in four months no one had taken him to task for it. This is the
point; no one comes back at you for anything you write, but imagine the
chaos you can create for the honest employer, the small business with a
shoestring workforce. I found this out for myself recently when a couple
of staff members were signed off for seemingly spurious reasons by
neighbouring GP colleagues………
Jim Hardy
60 Florida Street,
London E2 6LL
1. Hussey S. Sickness certification system in the United Kingdom:
qualitative study of views of general practitioners in Scotland. BMJ
2004;328:88-91
Competing interests:
None declared
Competing interests: No competing interests
WHAT ARE THE MOST RECENT GUIDELINES?
As the respondent from the Department of work and Pensions pointed
out there are serious misunderstandings about sick cerificates ,yet his
views were not picked up by the media as they are rather more complex than
a headline around 'Scottish GPs research in BMJ reports misuse of sick
notes.' (BMJ DECEMBER 2003) Was it 'research'?
Doctors need to inform those who consult them of the guidelines they
are obliged to conform to when issuing sick certificates. It would remind
both parties that they are not so flexible as some might think and that
doctors also needs to justify their decisions. If a request meets with
scepticism and a doctor decides to seek a second opinion then that should
be openly discussed with the person involved.
Let's not forget the massive collusion with the last Tory government
by the medical profession when there was a need to massage unemployment
figures - achieved with the help of huge increases in use of Incapacity
Benefit. People are often just used as pawns in political games - GPs who
refuse are right in resisting this manipulation of their role.
Most people have no idea that their medical information is being
passed on or who may read itand would want to discuss soome of the
diagnoses used with a GP before they are recorded.
How by the way are doctors' own sick certificates handled when the
majority do not register with a GP?
Competing interests:
None declared
Competing interests: No competing interests
Dear All,
As one in a program to become a military doctor in an army with
mandatory service, I have been informed about the lust of soldiers for the
"Gimmel" (Sick leave pass). This leads military doctors to doubt
everything they learnt in school, and suspect all soldiers of "searching
for a Gimmel". This may lead to detrimental outcomes, when the soldier is
really ill.
Additionally, sometimes R&R (rest and relaxation) is the required
treatment.
Solomon MS Gruber
Hadassah Medical School
Hebrew University,
Jerusalem, ISRAEL
Competing interests:
None declared
Competing interests: No competing interests
I am interested in the doctor who leaves the diagnosis box blank.
Having landed the role of Caldicott gaurdian to various bodies I could
argue a good case for doing this all the time. Anyone else in agreement?
If the GP is held to be gate - keeper, and has signed for legal
responsibility, why should he share sensitive diagnostic information with
a group of junior civil servants and line managers?
Competing interests:
None declared
Competing interests: No competing interests
It seems sick certificates stimulate the same concerns the world
over ( I
have worked in the UK, Australia and now in Canada). Sick certificates
(and their grander cousins the "insurance form") particularly seem to
challenge the patient doctor relationship because it is often a third
party
that demands them and not the patient. If we are honest with ourselves
how much is "time off work" part of the treatment plan for a patient. In
fact, when providing certificates we are, as mentioned by one
respondent, more often being policemen for employers, not doctors for
our patients.
From another angle we also must be mindful of the potential harm we
can do by providing a sick note "just because the patient demands it". We
certainly don't provide benzodiazepines or opiods based on the same
premise. I would argue that any professional relationship that is based
on fear of losing the patient or just "giving them what they demand" is
dysfunctional and needs to be terminated anyway.
And what is my cop out solution? Well here in Canada I am free to say
to
the patient that, unfortunately their government medical cover does not
include the cost of sick notes and there is a charge for them.
(actaully I believe the same applies in the UK does it not?). Very
quickly
they seem to become far less necessary when they are not free.
Competing interests:
None declared
Competing interests: No competing interests
Hussey et al (BMJ 2003; 0: 379496563-0) provide some interesting new
data which builds upon previous research findings, including that
commissioned by the Department for Work and Pensions (DWP). The DWP has
responsibility for both the policy in the area of state sickness
certification and the official guidance to registered medical
practitioners throughout Great Britain. From this perspective I offer the
following comments on the paper.
The DWP in fact replaced the former Department of Social Security and
the Department for Employment in June 2001 and is not 'a branch of the
DSS' as stated in the Introduction. The DWP statistics quoted [4.9 million
/ 3 million people] are misleading since they refer to a range of benefits
claimed by people of working age including those where there is no link to
sickness certification. A more appropriate statistic would be the
2.7million people of working age in the UK currently in receipt of a state
incapacity benefit; almost all of these people will have received sick
notes at some point.
The paper does not make clear when the field research was carried
out. This is a relevant because, following previous research findings,
updated guidance was issued by the DWP to all general practitioners in
April 2000 and April 2002.
A number of the references cited (Ref 5,7,8,19) relate to Scandinavia
where important contextual differences make comparison with the UK
difficult - the text does not make this clear.
The researchers adopted an approach to qualitative research which was
intended to 'examine the more sensitive areas of the general
practitioner's perspective'. This resulted in focus groups where '..one
facillitator was personally known to many of the participants..' and
'..many of the participants knew each other...' The paper does not
discuss the possible effects this might might have had on the data nor was
there any attempt to conduct one-to-one interviews to verify whether
participants views were being influenced by the structure of the focus
groups.
Only 3 of the focus groups were devoted to discussing emergent
themes, there appears to have been no clarification of issues with the
original focus groups or apparently with experienced GP principals.
Looking at the examples of GPs views provided in the appendices some
clearly relate to state benefits, such as Disability Living Allowance
(DLA), which have no direct connection with sickness certification.
Unfortunatly it is not clear to what extent overall these findings
actually relate to a lack of awareness by the GPs of their role in the
current system for state sickness certification (which seems to be
suggested by many of the comments) or to perceived difficulties in
practice to follow the correct procedures and guidance.
Finally, I note in passing that the researchers did not share their
findings with us but they apparently did share them with the BMA. The BMA
Public Affairs Division issued a Press Notice ahead of publication on
BMJ.com which resulted in extensive media coverage of certain aspects of
the findings on Monday 22 December 2003.
Competing interests:
Principal Medical Adviser, Department for Work and Pensions
Competing interests: No competing interests
Advice to patients on fitness for work - BMJ 2004; 328 (10Jan)
Dear Sir
Hussey et al (1)produce similar findings to other recent studies
(2)(3)about GPs’ advice on fitness for work but in your ‘Editor’s choice’
you appear to draw one principal conclusion: that much of the work is
‘philosophically untenable’. No one doubts that there are difficult
aspects to this work, as with much of clinical practice, but an important
additional perspective is that GPs have been poorly trained in this
important aspect of their day to day work. A challenge which the
Department for Work and Pensions (DWP) is only too anxious to address.
Your editorial also perpetuates the myth that GPs are acting solely
as agents for the DWP, presumably in the same way that they are agents of
the NHS when they issue a prescription ? In fact advice on work fitness
is an integral part of the clinical management of patients of working age.
The obligation to record the advice on a statement (eg Form Med 3) does
not detract from the fact that the doctor’s overriding consideration
should be to provide advice which will lead to the best clinical outcome
for the patient. Some of the examples cited by Hussey et al suggest that
this is not always the case - collusion between GP and patient may serve
neither party well. Good professional practice may indeed sometimes mean
challenging the patient’s view, much as a GP may do when requested to
prescribe a drug. But it is an extremely narrow view of advocacy to
believe that a skilled professional, such as a GP, should simply accede to
the patient’s wishes without any negotiation.
The Government has recognised the need for reforms in the area of
incapacity for work (4), including many of the changes called for by
Hussey and others. Employers do need to take greater ownership of absence
management and to avoid inappropriate medicalisation. But the GP’s
position in front-line healthcare inevitably means that they will remain a
key source of advice and influence to working patients for the foreseeable
future.
Good advice can often prevent the vicious spiral to long term
incapacity; avoidable worklessness has well recognised adverse effects on
health and is one of the key determinants of health inequalities (5).
Even though most doctors will recognise the link, particularly between
unemployment and poorer mental health, low self esteem and deprivation,
this is not always translated to their practice.
Given the relationship between work and health GPs need the skills
and knowledge to provide advice in a way which really does meet the best
interests of the patient in terms of job retention and vocational
rehabilitation. GP educators should take urgent note and recognise the
need for a step-change in thinking about this aspect of vocational
training and Continuing Professional Development. To support them in this
task DWP already provides a range of training resources, evidence based
guidance, online training and a national network of medical officers
[visit www.dwp.gov.uk/medical].
Yours sincerely
Professor Mansel Aylward CB
Chief Medical Adviser
Department for Work and Pensions
1) Hussey et al. Sickness certification system in the United
Kingdom: qualitative study of the views of general practitioners in
Scotland. BMJ 2004; 328: 88-91
2) Hiscock J and Ritchie J (2001) The role of GPs in Sickness
Certification National Centre for Social Research, London DWP
Research Report 148
3) O’Hara R et al. The Profile of Patients’ Occupational Health in
Primary Care. Health & Safety Laboratory. Report HEF/03/10 HSL
November 2003
4) Pathways to Work: Helping people into employment. Cm 5690
Department for Work and Pensions, Nov 2002, The Stationery Office; and
Pathways to Work - The Government’s response and action plan Cm 5830
Department for Work and Pensions, June 2003, The Stationery Office
5) Acheson D. (Chair) 1998, Independent Inquiry into Inequalities
in Health Report, London, The Stationery Office
Competing interests:
None declared
Competing interests: No competing interests