Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Sick notes - an ethical muddle for the GMC to tackle
- Anthony N Williams (29 March 2008)
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Sick Note, Fit Note; No Note?
- Martyn JF Davidson (30 March 2008)
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Work, sickness and education.
- William G Pickering (1 April 2008)
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Waiting lists?
- Declan P Fox (1 April 2008)
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Sick Sick Notes (sic)
- Peter G Hutchison, Colin Jamieson (3 April 2008)
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Sickness absence - partnership with relevant stakeholders needed
- See-Muah Lee, Judy Sng, Gerald C H Koh, David Koh (22 April 2008)
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Sick Notes or Fit for Purpose Notes?
- David Snashall (29 April 2008)
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Anthony N Williams, Consultant Occupational Physician Working Fit Ltd, PO Box 389, Temple Ewell, Dover CT16 9BF
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The issue of sickness absence has recently been highlighted by Dame Carol Black in her report for the Departments of Health, and Work & Pensions (1). I note that it is now acceptable to use the phrase 'unaudited farce' in public and in the BMJ in relation to sick notes by a highly respected senior occupational physician (2). A major part of the workload of many occupational physicians involves sickness absence, and much of this involves disagreeing with the advice given by GPs via sick notes. In most areas of medicine specialist doctors guide and advise generalists. To employ one doctor just to disagree with another is an unusual concept in healthcare. The reason for this is said to be 'ethics'. GPs are ethically obliged to be the patient advocate, so when the patient says they do not feel well enough to work, the GP is expected to support them. A fine principle perhaps, but clearly much abused. GPs state that advising on fitness to work is an area they are untrained for. In many cases however, the issue is not a challenging medical decision; the patient has long since recovered (if there ever was any disease process) and they now have nothing medically significant wrong with them. The argument therefore hinges on 'ethics' and the distinction between giving patients what they want, or giving them what they and society need. For ethics to create such a conflict at a suggested cost to society of several billion pounds a year suggests a profound ethical muddle. As the GMC holds the key responsibility for medical ethics in UK, this suggests that the GMC holds a trump card for the solution to a significant percentage of sickness absence in UK. This was not made clear in the Black report, but I suggest it is an area worth exploring further. (1) Black C. Working for a healthier tomorrow. 2008. www.workingforhealth.gov.uk/documents/working-for-a-healthier-tomorrow- tagged.pdf. (2) Snashall D. Health of the working age population. BMJ 2008;336:682. Competing interests: None declared |
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Martyn JF Davidson, Group Head of Occupational Health Centrica Plc SL4 5GD
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David Snashall's description of the current sick note system as 'an unaudited farce' demonstrates a delightful but unusual honesty. 'Working for a Healthier Tomorrow' pins considerable faith on moving to a 'Fit Note'. It is unrealistic for the General Practitioner to be expected not only to assess health but also to understand the detail of job requirements, which may be well outside their personal experience, within a brief consultation. It's time to demedicalise the process wherever that is possible. Recognition began in 1982 with the extension of self certification from the first 3 days to the first 7 days of absence from work. There is no good reason why this period could not be extended. A recent small trial within our business, whereby the requirement to submit a sick note was replaced with the offer of early support and assessment by occupational health, was very positively received. The workforce felt a greater degree of trust (rather than the usual suspicion) was being shown toward them by management; and there was even a small reduction in lost working days over the 6 month trial period. The problem is substantial. The solution will not come from tinkering within existing systems. Competing interests: MD has been invited to take part in discussions with Dame Carol Black's department regarding early interventions in the workplace. |
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William G Pickering, Doctor NE3
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Work, sickness and education. Even allowing for Dr Snashall’s exalted medico-political position and partisan view, a little vision would still have been welcome. Endemic sickness absence problems in the UK, we learn, can be remedied by “real investment” (taxpayers’ money), and “government support” for more occupational health. Not a word about existing lay and medical services adapting and changing their modus operandi at no extra cost [1,2]. More health?: more money; the incessant UK medical refrain. And governments usually fall for it. “Why” writes the puzzled Dr Snashall “has the problem not been sorted out before in a country with a NHS and a well developed benefits system?”. Perhaps because they and their ambient mentality are the root problems. GP issued “sick notes” are not to Dr Snashall’s liking, and the alternative is not to the GPs’ liking, who want training (as though initiative and a standard medical education stand for nothing), and there are “workload implications” [3]. Yes: by deterring some claimants at source it might reduce it. Many OH doctors work from tick box sheets; let the GP’s do the same to assess fitness or unfitness for work. It would cost almost nothing. The only minds it wouldn’t concentrate are patients who are genuinely unfit to work. OH doctors, with ironic circumlocution, constantly write to GPs for medical information about allegedly unfit employees. The GPs’ fee would have to be forgone if they were in the driving seat. Still, no time would be wasted while waiting for their reply. Work is good for most people’s health, as any lay person well knows – they do not need doctors to tell them. Dissemblers, meanwhile, require more action from management [1,2]. Note also however, well meaning ‘square’ employees sometimes find themselves in ‘round hole’ jobs: and it can make them ill. If there is any money to spend on the “working age population”, divert it to education, at school and after. It is a time- honoured enabler and health giver, and often a much sounder investment than more medicine [4,5]. William G Pickering. 30.3.08 wgpi@hotmail.com References: 1. Pickering W G. Occupational communication. http://bmj.com/cgi/eletters/336/7643/519#192008, 12 Mar 2008 2. Pickering W G. Occupational medicalisation. http://bmj.com/cgi/eletters/336/7645/631#192519, 24 Mar 2008 3. Caroline White Report calls for shake up in management of sick notes. BMJ, Mar 2008; 336: 631 ; doi:10.1136/bmj.39524.523403.DB 4. Sir Donald Acheson. Independent Inquiry into inequalities in health. 1998. published by The Stationery Office as ISBN 0 11 322173 8. (Part 2, Education). www.archive.official- documents.co.uk/document/doh/ih/ih.htm 5. Pickering W G. The state of education and the health services http://bmj.com/cgi/eletters/334/7591/0#162528, 17 Mar 2007 Competing interests: None declared |
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Declan P Fox, Freelance physician Varies, based at home, Newtownstewart, N Ireland BT784NP
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Sir Insufficient attention has been paid to the simple problem of providing adequate treatment for people with illnesses or injuries preventing them from working. Is it fair to expect manual and semi- skilled workers to fork out hundreds or thousands of pounds for speedy treatment? A student loan-type system might be useful!! But unlikely to be appreciated! Yet Dame Carol and her supporters seem to gloss over the length of waiting lists for basic bread and butter treatment. Why?? As for GPs disagreeing with other doctors about fitness for work---is it not time that we all recognised our limitations? I am more than happy to refer to an experienced Occ Health Physician in the tiny percentage of cases where the employer has access to same. In the majority of cases, I certainly reserve my right to argue against decisions made by non-medically qualified personnel. Competing interests: None declared |
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Peter G Hutchison, GP Greyfriars Medical Centre, Dumfries DG1 1DL, Colin Jamieson
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Dear sir We take exception to David Snashall's use of the word ‘farcical' in his description of the ‘sick note system’ (1); it is not a word used in Carol Black's report (2) and is not helpful. The fact that a doctor allows a patient's individual rights and welfare to take precedence over other matters when they present with ill health is not unreasonable, especially as ‘…in contrast to many European countries, occupational health services were not incorporated into the NHS at inception’ as stated in the editorial. In other words, occupational health was deliberately kept as an independent service under the direct control and funding of employers. It is sad that employers have not taken this responsibility seriously and that ‘…occupational health services are accessible to only 3% of the working population in the UK’. We have to remember that GPs have other minor considerations to take into account such as diagnosis, treatment and management of the patient's medical condition that may be regarded by patients, society and the majority of the medical profession to take precedence over occupational health matters. Having said that, however, GPs are all well aware of the health benefits of work and the damaging effects of a patient over- enthusiastically adopting the ‘sick role’, so it is normal practice to make some attempts to encourage a return to work, both for the patient's as well as the employer's benefit. In an ideal world, the GP would communicate with an employer to gain background information about the working environment and to discuss possible measures to encourage an early return to work, but the NHS does not have the time and is not funded for this, as already mentioned. The proposal to integrate occupational health into mainstream medicine runs the risk of extra work with no resources. It is not realistic for a GP to know the exact circumstances of each patient's work – that should be the remit of an occupational health physician. In our opinion, the government or employers need to develop a properly funded and professionally structured occupational health service which can positively liaise with Primary Care. Yours sincerely, Dr Peter Hutchison, General Practitioner, Greyfriars Medical Centre, Dumfries Dr Colin Jamieson, Director of Occupational Health Services, NHS Dumfries & Galloway References: (1) Snashall D. Health of the working age population. BMJ 2008;336:682 (2) Black C. Working for a healthier tomorrow. 2008. www.workingforhealth.gov.uk/documents/working-for-a-healthier-tomorrow- tagged.pdf Competing interests: None declared |
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See-Muah Lee, Adjunct Lecturer COFM Dept, Yong Loo Lin School of Medicine, National University of Singapore, Judy Sng, Gerald C H Koh, David Koh
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Dame Carol Black must be commended for her report on Working for a Better Tomorrow (1), which outlined the strategies for addressing the needs of working people, in particular, the issue of sickness absence. Her proposed strategies seem simple enough - get workers back to work even if they are not 100% fit, and businesses to do more to recognize the working potential of those with disabilities and chronic illnesses. In particular, doctors, especially GPs on whose shoulders the responsibility of certifying sickness predominantly fall, must realize that work is good for health, and consequently change their certification behavior. A point which may not have been addressed adequately is the worker- patient himself/herself. The patient plays a major role in determining whether he/she resumes work or not. In a large number of cases, such as work related stress, or even backache, doctors have to rely on the patients' account. There may be scarcely any objective signs for determination of whether a person can work or not. Few doctors would jeopardize the relationship of trust with their patients by refuting their unwillingness to work because of a self perception of being medically unfit to do so. Even fewer would relish the opportunity of a confrontation with the union on coercing a worker to work when the worker perceives he/she is not fit to do so, especially in the absence of objective methods to determine fitness to work. On the other hand, the worker who is ill but is willing to, and can, work, is quite likely able to do so after discussions and agreement with his supervisors; barring special circumstances, such as safety sensitive work environments. A counter instructive point is that of sickness presenteeism (2,3), that is, working through illness, examples of which are rife in the healthcare profession. It is well established that sickness absence has a multifactorial aetiology (4), many of which are non-medical, and some of which are occupational health related. A positive outcome to manage sickness absence can be best achieved through partnership with all the relevant stakeholders, starting with the worker-patient, the union, the management, the well trained healthcare professional, and the occupational health service, whose special expertise it is to identify and help manage work related hazards. References 1. Black C. Working for a healthier tomorrow. Stationery Office, London (2008). 2. Kivimäki M, Head J, Ferrie JE, Hemingway H, Shipley MJ, Vahtera J, Marmot MG. Working While Ill as a Risk Factor for Serious Coronary Events:The Whitehall II Study, American Journal of Public Health, 95 (2005), pp. 98-102. 3. Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T. Challenge of culture, conscience, and contract to general practitioners' care of their own health: qualitative study, BMJ, 323 (2001), pp. 728-731. 4. Health and Safety Executive. Managing sickness absence. 2007: http://www.hse.gov.uk/sicknessabsence/guidancehome.htm (Accessed March 24, 2008). Competing interests: None declared |
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David Snashall, senior lecturer in occupational medicine King’s College London School of Medicine, Occupational Health Department, St Thomas’s Hospital
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The issue of sick notes has, predictably, been highlighted by various responders to my editorial on Dame Carol Black’s Review of the health of the working age population1. GPs are contractually obliged to complete medical statements for those of their patients who are claiming Statutory Sick Pay (SSP) or a state benefit. Legally and ethically, doctors must fill in these certificates accurately and in good faith. The vast majority of patients actually use the Med3 or equivalent not to claim SSP but as evidence to support their contention that they should refrain from work. They will generally receive considerably more than the statutory minimum payment. In such cases, the employer, not the state, pays the employee the difference and that employer has a right to ensure that an employee has sought reasonable advice on their health status (not necessarily from a doctor). The employer owns the decision as to whether to continue to pay the putatively sick employee according to the reasonableness of the information and supporting evidence received. Sick notes in their present form are problematic in a number of ways. First, for reasons I have described, most of the time they are not used for their original intended purpose. Then, rather than being a description of why somebody is unable to work, the sick note usually contains a diagnosis, often bewildering to the patient and to the employer – who should not be seeing personal clinical information anyway - or is unreadable, and possibly even untrue. Vague diagnoses are often submitted in order to mask the real reason for sickness absence which may be a social problem or something embarrassing. As See-Muah Lee et al2 point out, patients usually make up their own minds as to whether they can work or not and general practitioners usually have to agree with them, sometimes but not always because they do not want to get into an argument and compromise the doctor/patient relationship. As tokens of the doctor/patient relationship, sick notes (like prescriptions) are very powerful tools and can have profound effects on patients’ illness behaviour and their expectations of recovery. One of the themes of Dame Carol Black’s review was that prolonged absence from work, legitimised by recurrent or long term sick certification, can be inappropriate because it is an easy alternative to managing somebody back to health and work but can lead to demoralisation and chronic ill-health. I described the sicknote system as an unaudited farce because of its unfitness for purpose and the fact that it is not audited. It could be audited in the same way as prescriptions are audited. The change to a “fit note” (not the same as a “well note”) envisaged in the Black review would simply require the general practitioner, in those circumstances where it would be possible and useful to do so, to indicate what was causing the patient to be unfit for work and give some simple guidance on how a return to work might be managed. This would be useful in some cases, not terribly difficult to accomplish or needing specialist expertise and would not compromise the GPs role as a patient advocate – there are good health-promoting reasons for getting people back to work as quickly as possible, even if they are not 100% fit. The recent BMJ poll showed how unpopular sick notes are with GP’s who would prefer them to be filled in by occupational health staff – an entirely impractical scenario on account of the tiny number of occupational health professionals. More radical is Martyn Davidson’s suggestion to demedicalise the process further and institute early support and case management by the employer3. The Department for Work and Pensions may have to rely on certification for state benefit purposes, but beyond that narrow remit a more flexible system, incorporating “fit notes” would be a step in the right direction for employers, employees and GPs. Another helpful initiative would be more facilities for the rapid treatment of work-preventing illness and injury as described by Declan Fox4. 1. Health of the working age population. Snashall D BMJ2008; 336:682 2. Sickness absence – partnership with relevant stakeholders needed. See- Muah Lee et al, 22 April, 2008 3. Sick note, Fit note; No Note? Martyn J F Davidson, 30 March 2008 4. Waiting Lists? Declan P Fox, 1 April 2008 Competing interests: DS gave evidence to this review and, as president of the Faculty of Occupational Medicine, is a member of the Academy of Royal Colleges of which Dame Carol Black is the chair. Provenance and peer review |
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