Is there any chance of a sick cert, doc?

MEDICAL MATTERS: Taking sickness certs away from GPs

APPARENTLY THE Department of Social Protection is considering proposals that workers not be allowed to have their sick certificates signed by their own GP.

According to The Sunday Times report, employees may be “forced to bypass their own GP and visit a doctor who has been approved by their company”.

Whatever about a coercive element for patients/employees, the present sickness certification system is full of pitfalls for GPs. For doctors it has become increasingly difficult to balance patient advocacy and the role of “benefit gatekeeper”.

As the practice of medicine has moved toward a more equal balance in the doctor/patient relationship, obtaining sick certs is an activity that has failed to budge from an outdated adult-child dynamic of doctor knows best.

A supplicant patient – perhaps one they are meeting for the first time – approaches the doctor and asks, “Is there any chance of a sick cert for the next few days?” Ideally, the benign figure at the other side of the desk says “of course”, much as a parent might bestow pocket money on a well-behaved child.

As tokens of the doctor/patient relationship, sick notes are very powerful tools and can have profound effects on patients’ illness behaviour and their expectations of recovery. In practice, patients usually make up their own minds as to whether they can work or not; when their doctor agrees, the process is a smooth one.

However, when there is disagreement – often about return-to-work dates and a doctor’s attempt to apply an evidence-based strategy of returning a little earlier as part of a recognised rehabilitation programme – sick certification becomes a stressful encounter for both doctor and patient.

A 2007 survey of GPs in the west of Ireland published in the Journal of Irish General Practice found that while just 1 per cent of respondents felt the current system caused “an extreme difficulty” with either workload or the doctor-patient relationship, there was a need for strategies in situations where they found it difficult to justify writing a sick cert. The most popular strategy was direct confrontation with the patient, followed by waiting for a Department of Social Protection medical review to take place.

Referring the patient to a colleague or occupational health specialist was another option.

Some 40 per cent of family doctors felt that self-certification by the patient/employee would be worth considering.

A qualitative study of sickness certification in general practice in Ireland, just published in the European Journal of General Practice, was based on in-depth interviews with Irish GPs. The authors found GPs were concerned with breaching patient confidentiality and, in particular, disclosing illness to employers. They reported feeling inadequate in dealing with some cases requesting sick leave, including when the certification was for adverse social circumstances.

In a 2008 poll of GPs in the UK by the British Medical Journal, asking “Should responsibility for signing people off sick be transferred from GPs to occupational health teams?” 56 per cent of GPs were in favour.

There is certainly a groundswell of support for the demedicalisation of the sickness certification system. Instead, why not introduce a process of early support and case management by the employer? Remove GPs from their central certifying role, and make properly independent occupational health services available to all employees.

It’s a system already proposed for the UK by Dame Carol Black, Britain’s national director of health and work, in a report on sickness absence. She concluded that prolonged absence from work, legitimised by recurrent sick certification, becomes an easy alternative to managing somebody back to health and work.

With expenditure on sickness benefit rising from €330 million in 2001 to €876 million last year, and pressure on Minister for Social Protection Joan Burton to further prune the social welfare budget, alternative ways of doing things are very much on the agenda. It’s a good opportunity to demedicalise the entire sick cert process, the only obvious downside being to deprive Isme’s Mark Fielding of his memorable line that “doctors are giving out sick certs like snuff at a wake”.