Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Qualitative study of certifying medical practitioners
- Philip Sawney (23 December 2003)
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Prostituting ourselves for certificates?
- Paul V Mackey (9 January 2004)
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Data Protection Act again?
- David J Young (11 January 2004)
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Military Doctors
- Solomon MS Gruber (11 January 2004)
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Sick notes - what are the guidelines ?
- susanne McCabe (14 January 2004)
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We ARE agents of social control
- James N Hardy (15 January 2004)
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Advice to patients on fitness for work - BMJ 2004; 328 (10Jan)
- Mansel Aylward (22 January 2004)
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Philip Sawney, Principal Medical Adviser Department for Work and Pension
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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 |
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Paul V Mackey, GP Fort St John Canada V1J 2B1
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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 |
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David J Young, GP Principal/PCare Tutor Derby DE215DH
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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 |
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Solomon MS Gruber, Student Hadassah Medical School, Hebrew University, Jerusalem, Israel
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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
Competing interests: None declared |
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susanne McCabe, retired home
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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 |
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James N Hardy, GP Principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
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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
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 |
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Mansel Aylward, Chief Medical Adviser Department for Work and Pensions, Room 640, 1-11 John Adam Street, London WC2N 6HT
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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
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 |
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