Focus Group

Theme ‘Strategies’

The problem is it’s management using GPs... I'll give him a med 3 no questions asked. Path of least resistance. Don't want to fight. Complainant type patient. I have never said to anyone 'I don't believe you', I don’t think it helps. Give them time out. Help patients evaluate their situation, with a little time off.

That's the back of the form where you get them assessed. GPs are useful to business, as then companies don’t have to deal with employee issues.

Shouldn’t use med 3 to follow up patients -reply- that’s what patients will come back for.

Patient wants a line, that's fine. I acquiesce but feel uncomfortable. You make a variety of different decisions in different circumstances. I'm now in the trap of signing her off. No worries about signing anyone off. I could justify giving it to everyone. If the dustman comes in will you stand in his way if he wants a sick-note? Don't want to attempt to tackle this. But it's also my refusal of taking a role which may not be a GP's role. I wouldn’t use it as a power struggle, but I don't issue certificates on demand. I don't think you should just give people sick lines on demand. Need to confront the issue. Reach a plan with patient. Help find other solutions. Agree to line with provisos. Bargain. Shorten the time on lines. May help patient to have real reason on med 3 [in the open]. Encourage people to take time off if they need it.

I give people the benefit of the doubt on the first occasion. Sometimes I have used sick lines as a means of making an employer do something. The med 3 consultation itself can help patient to express feelings.

3

Easier to just give a line. Take what patient says at face value. Risks of non- acquiescence. I just give out lines, because role is imposed. And I've also heard of a GP who would never sign. I don't think I've yet been in a position to say, "No, I think that's quite enough time, now go back to work regardless of what you say". I examine them always, each time if I can. It's time consuming for me, but keeps my conscience happy. If I have some kind of objective proof rather than just a hint, or a, or a feeling that someone is swinging the lead. So if I've got some kind of proof, it keeps me happy. If I see them on a Tuesday I say, "In my opinion, you're fit to go back next Monday." I used to ask the RMO for a 2^nd opinion. I'm increasingly more honest with patients. If I see deception, I won't buy that any more. I negotiate what to write. Negotiate another solution [to line]. Give patients time out. Help them over a crisis. Used consultation therapeutically to find a better solution for patient. A break from a horrible job.

Use for opportunistic healthcare/screening. Doctors don't like saying no. I do not feel happy with turning down certificates [remote] Need to persuade self-employed to stay off work.

You have to take the patient’s word. Acquiescing is less stress. I seldom refuse. I don’t take hard line. Not my fight. I would give them a line since they are there. You've got to take their side. I challenged when I was a registrar. I won’t sign if not seen. By refusing to backdate, it may cause unnecessary consultations. I would sometimes challenge. You can get known as always giving lines. Do you ever just say no? "No". I couldn’t backdate for a long period. Ad conditions/provisos. Give them some space. Give them a short line to bring them back.

Some patients want to work when unfit. It’s paternalistic to use lines to bring patients back for review.

You tend to just do it. We all acquiesce to the patient to some degree. But there have been times when I have said no more lines. I tell them, people with your disability can work, with training.

Patient getting incapacity illegally. –I warned her to give her a chance to sort it out.

Not complete acquiescence, what I would do, is refer on. What about if an alcoholic, gets sack for being drunk?- reply- It’s a treatable illness. What do you do with a patient you didn’t see when ill?.- Long argument about sticking to the rules. Acquiesce to a patient who is threatening violence.

[Consensus]- refuse if < 1 week. I think that it's our role as GPs to try and get rid of benefit mentality by challenging certificates.- reply- If the patient says he's got severe backache and he really just can't work, and you know that he is swinging the lead; are you going to call him a liar and not give him a certificate? If you think somebody is fit for work, you have got to tell them that you think they are fit for work, and it is your job to do that. A young guy who is drinking so much, every weekend and is useless until Wednesday then no I don't give out certificates, I give them a serious yoking and a referral to the substance abuse programme. - reply- But you need to give them a sicknote until their substance abuse is taken under control. You are really at it and there is no way I am going to give you another sickness certificate as long as you or I live. I refused to certify girl who refused to engage with any therapy. Because if you are single-handed you know they can’t play one off against the other. I would never give a line to cover a backdated time unless I saw patient when ill.- reply- other GPs in focus group would. I mean all you can do is play it by ear. Every time I issue a sick note I actually say to the patient, when is this going to end? I work to some sort of contract with the patient.

I may give < 1 week [remote]. I've had to say "No you are not getting a final line you are not better yet."[rural small town] I have got much more trouble getting people to accept lines (part time crofters). [remote].

7

I’m uncomfortable but acquiesce. Avoid conflict. Yeah we're too soft.

Two groups: long term sick and short-term illness which are entirely different. GPs do feel very uncomfortable about saying you have to get back to work now. It would be more honest to say, 'listen matey, I'm a taxpayer, get on and do some work'-reply- all they'll do is go around to the next doctor and complain of the stress and depression you've just caused by you know refusing to sign their form. There's always scope you know for making a few inferred comments in the IB report as to whether you really feel the patient is as bad as they make out. I'm strict about not giving certificates for <1 week. Use to review patient. Work with Occupational Health to rehab and get them back to work.

At times we say "Stuff that, you're back to work matey."

8

I ended up giving her a sick-line to keep the peace. Nothing wrong with saying you seem to me to be fit. If you feel you are being bullied, maybe need to stand your ground. If you if you are too wimpy about it I don't think it encourages alcoholics to see that they can change. A patient was under the impression that I would support his blatant lie.[registrar]. I was very pleased in a way to tell this lady that I knew what she was up to and the sick-line stopped. I am honest with him. Two-way process. Benefit of doubt short term.... but I say "This will have to stop sometime." If patients really need time off.

Refuse lines to alcoholics, so drinking behaviour not rewarded.

Registrars

The temptation to follow the path of least resistance, like the Principals do. Established GPs don't tend to fight. Easier just to go with patients demands rather than create a big fight and problems for yourself. Older partners don’t rock the boat. Its only because they have asked me for a line that I am giving them a line, its not because I am ‘advising’ it. More work for GP not to give in, forms etc. You’re playing a role in the game. Most GPs acquiesce. I will usually give short term line. When somebody is insistent. Shouldn’t acquiesce just because of patient poverty. If surgery time pressure. just looking after yourself. No to patient who wanted a sickline after resigning from job. I won’t sign them off if they are fit. Challenge young fit people who don’t want to work. Principals don’t challenge appropriately. Not < 1 week, I say med 3 is legal document. Patients sometimes scream at me when I refuse. I'm actually trying to look after patients’ best interests, [when I challenge them]. We may as well work in the employment agency, as we have to do job counselling. Difficult to challenge long term lines from other GPs. Patient was surprised to be challenged, which made me feel bad. Self-certifying makes it patient’s decision.

It’s not a battlefield. Patients may need time out to relax. Not argue, try and reason. You have got to have a bit of come and go.

Locums

I will backdate lines. If they can't face going into work I tend to give them a line; its up to them whether they get laid off for absences. I just say OK there's your line. I tend to change my practice depending on which practice I'm in. They probably say 'get the locum to sign them' (laughter). I do what the receptionist says.-reply- I may not. You can discuss it but you don't confront. I feel much better at outflanking rather than attacking these problems. I reflect things back to patients. You can sign them off for a short period and tell them to go back to see the principal, who knows them-reply- Yes I think I'd do that as well, just a cop out -reply- Yeh, as a locum you're probably more likely to just acquiesce; as a partner you maybe more likely to have an idea where they are going over time. I'm a lot more relaxed about it than when I was a principal, because I'm probably not going to see them again. Don't have confrontations about sick lines as a locum. I want to get through my surgery, it takes longer to have confrontations-reply- It’s bad for your health to have confrontations. You can explain to the patient that it might be a bad idea for them to keep on the sick because x y & z but yet if they do want to I'm not going to stand in their way

I sometimes challenge patients.

11

I just give them a shorter line and say 'well come back and see your normal Dr. I make murmurs 'I can't do this for ever'. I can understand all 3 [strategy quotes] at one stage or another. Normally negotiate. I challenged eventually, and it was better for patient. As time goes on I would think you mellow somewhat and do more to avoid a confrontation. When I was a trainee, there was a perception that you were acting as gatekeeper for the DSS, now you're bombarded with paper and worked so much that I can certainly imagine people being less rigorous about it than they were when they first qualified. I may set a timescale. I may refer. If it’s not medical, I’ll say ‘You have to try and solve that problem yourself’ Use a mixture of things. Discussion may help. Should confront, rather than report anonymously. I do confront. If I refer I say 'I don't know where I'm going in this; I wouldn't leave them blindly in that one, that would be unfair. I bargain. If I feel it’s hopeless, I acquiesce.

I know a Practice which has sick-note surgeries. I use the sick-line consultation to check everything is being done.

GP1 My line is, if I've got somebody who I think is, ... is, doing the system. I examine them always, each time if I can. It's time consuming for me, but keeps my conscience happy., .. I've got some kind of objective proof rather than just a hint, or a feeling that someone is swinging the lead.

GP2: ….so I've just given up worrying about whether I'm acting as the gatekeeper to the DSS system or benefits agency system or whatever it is. Too many other things to think about too many other priorities. Terribly sorry. I just don't give a moment's thought. Patient wants a line, that's fine, here you are.

GP3: After the benefits agency fraud hotline was put out about 18 months ago I made a few phone calls (I did the 141 before dialling) I reported information that I had got, circumstantially, you know third party information to the effect that this person should have a review of their DLA

GP1: Yeah, have you ever written something really, really crap on a Med 3, you know?

GP2: Yeah, I write 'neurasthenia' and I scribble it so even I can't read it, and they have never ever asked for clarification, so they are obviously quite happy for you just to scrawl something totally illegible

GP3: I did actually once know somebody who wrote 'haematomentia' on it;….really!

GP4: Good god

GP3: Which means just 'bloody minded'

GP1: I once got myself into a real difficult situation where a patient didn't come to me for ten years because of me refusing her a sick line. She was wanting to extend her sickness period because of back pain and I couldn't find any evidence of that. At that time I was a young, I suppose what you would call now a GP Registrar and eh full of this 'Oh this is the right thing to do', I don't think I can sign you off' which just destroyed the relationship, she was aghast, she couldn't believe it 'I can't believe, you are telling me I don't have back pain, but I do have back pain'. Well I said 'I cannot find any great evidence of that, that would stop you working'…… and she never came to see me for ten years.

GP1: I think that, "I would go to work in this situation," is one of the things…. I would work with the flu. That very often happens to me. A patient comes in with a streaming cold and they say "I want a certificate" and I feel like saying "listen, I can't stand up today. So, you know… go away".

GP1: I had a lady just before lunch time, one time, who came in and was absolutely academy award performance she couldn't sit down, back pain agony (group chuckling) furrowed brow, you know, almost out in a cold sweat and straight leg raise the whole lot, I couldn't, couldn't trip her up, so anyway (laughing) I had to give her the line. So this was about 5 to 1, I was just going home for my lunch about 10 minutes later, I saw her walking at a rapid pace up the back, fitter than, than Linford Christie, you know, and she'd pulled the wool …and I just laughed……. But she won't do it again, I mean obviously (general laughter) That was her one and only dupe on me.

GP1: About once a year, I invite the med 7 to call them in, thinking perhaps we ought to use that more often. But if they want us to do these things more often, then of course what they should do is to put a fee against it. You know if there was a fiver every time we suggested somebody to go to the RMO we might get a more accurate system.

GP2 Every time we took someone off the sick

GP1 Money well spent

GP3 One of my partners suggested that the way to deal with it is to give every

Practice their own social security budget. And then things would really happen.

GP4 I wouldn't say that 'cos they will. The government haven’t thought of that yet.

Practice type:

Urban o

suburban o

rural o

remote o

Training Practice:

Yes o

No o

Full time partner

o

Part time partner

o

Registrar

o

Assistant/retainer

o

Locum

o

Other (state)

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Police surgeon

o

University post

o

Assoc Adviser

o

Occupational medicine

o

LHCC

o

LMC

o

BMA

o

Hospital clinical session

o

< 5

6-10

11-15

16-20

21-25

26-30

>30

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

over 65

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