Intended for healthcare professionals

Primary Care

Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland

BMJ 2004; 328 doi: (Published 09 January 2004) Cite this as: BMJ 2004;328:88
  1. Susan Hussey, honorary clinical research fellow (Susan.Hussey{at},
  2. Pat Hoddinott, clinical research fellow2,
  3. Phil Wilson, senior research fellow3,
  4. Jon Dowell, senior lecturer4,
  5. Rosaline Barbour, professor5
  1. 1Research and Development Office NHS Highland, The Greenhouse, Beechwood Business Park North, Inverness IV2 3ED
  2. 2Highlands and Islands Health Research Institute, The Greenhouse, Beechwood Business ParkNorth
  3. 3Department of General Practice, University of Glasgow, Glasgow G12 0RR
  4. 4Tayside Centre for General Practice, Dundee DD2 4AD
  5. 5School of Nursing and Midwifery, Dundee DD1 4HJ
  1. Correspondence to: S Hussey
  • Accepted 11 November 2003


Objectives To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change.

Design Qualitative focus group study consisting of 11 focus groups with 67 participants.

Setting General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland.

Sample Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes.

Results General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They seemed to develop various operational strategies for its implementation. There appeared to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes.

Conclusions Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system, before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered.


  • Funding All authors were responsible for the study design, data analysis, and writing the article. SH, PH, PW, and JD were responsible for data collection and checking the transcripts. Jean Taylor, Donalda Morrison, and Jill Sutherland were responsible for transcribing the interviews, with help from SH and PW. SH constructed the matrices. Ann Lewins (department of sociology, University of Surrey) provided consultancy for the Atlas Ti computer package. Jonathan Fagerson helped with data collection. Jackie Alston helped SH with data entry. SH will act as guarantor for the paper.

  • Funding Chief Scientist Office, Scottish Executive. Additional financial support was provided through the Research Practice Scheme, Chief Scientist Office.

  • Funding None.

  • Competing interests PW and PH have received fees for completing disability forms for the Department of Work and Pensions. RB acted as a consultant for a project commissioned by the Department of Work and Pensions

  • Ethical approval Not required.

  • Accepted 11 November 2003
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