Dr David Turner on whether there may a be a solution to the age-old problem of the sick note for GPs
It feels like a debate that has been rumbling on for as long as I have been a GP. Love them or hate them, sick notes are associated with GPs (in the eyes of the public at least) as much as stethoscopes and prescriptions are. I feel genuinely compromised as to whether the issuing of sick notes should continue to be the role of the family doctor or not.
Being the only professional that can excuse a sick patient from work and legally give them time off to recover is a huge privilege and responsibility. On the one hand, we often are the professional who does know the patient best and most able to judge if they are fit to work or not. But on the other hand, the refusal of a sick note for a patient we deem fit for work can cut right through the doctor-patient relationship, damaging it irrevocably.
Like with everything in the NHS, the problem arises when the sick chit system is abused. We have all sat there with an aggressive looking patient in front of us, whose reason to be excused work is – to say the least – a bit flaky. Do we choose an argument with an individual who looks like they would not see the funny side of a spilt pint; or quickly issue a certificate and expediate a pain free end to the consultation? I guess most of us would choose the latter.
There have been suggestions that medical certification should be taken out of the hands of GPs entirely and a separate doctor, working for the Department of Work and Pensions should do this work. In the case of the long-term sick this would certainly make sense, but what about short-term sickness? Would we really want every chef with gastroenteritis to have to see a DWP doctor to get time off work?
There is no single simple solution to this age-old problem. One idea I do like though is how the military issue medical certificates. During my time working on military bases, I became familiar with the way the forces deal with illness. Their sick chits are a list of all the conceivable jobs a member of the forces could be asked to perform, and as GPs we were advised to highlight the tasks they could still undertake. So, for example someone with a facial infection might be exempt from shaving but still deemed fit to perform parade ground drill. An officer once told me that even with all four limbs broken, a soldier may still be fit enough to sit in the guard room and watch a security monitor. The system is like a more sophisticated version of the fit note system we have in the NHS.
The Government are talking about how important it is to get the long-term sick back into work, may be this could be the way forward. I do think this would need to be undertaken by an occupational health doctor, but with enough thought and imagination it may be possible to find some sort of work for a lot of the people currently signed off sick.
Dr David Turner is a GP in Hertfordshire
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We have to face facts – at the root of the burgeoning welfare is us signing certificates. Take it out if our hands entirely. – as king as we are nit the expected to write ‘appeals’ letters
(Kudos, sir, for calling them the traditional “sick” note, not the loathsome modern bastardisation “fit” note.)
Agree with SF, the inbuilt bias of being the patient’s advocate compromises our ability to properly adjudicate on sick notes. The burgeoning welfare bill will only be impacted by independent assessments.
Is the national not working crisis enabled and amplified by ready access to texted MED 3 certificates requested on an e-consultation ? Maybe face to face better for this one?
As far back as 1996, GPs (and Hospital Doctors!) in New Zealand filled out a form somewhat similar to the descriptiom of the military one, from which the employer, if short term, would find something the worker could do, if possible, and if longer term, would have advice from ACC. Employers seemed to be much better at negotiating activities with workers, that worked out well. Possibly because pay for partial work was higher than pay for ‘off sick’. People even got ‘fetched’ into work if unable to travel alone, etc
The sick note itself has the want : need paradox inbuilt. Those that need, don’t want (the stubborn or stoic) and those that want, don’t need (those that haven’t learnt to work).
My mother worked in a school where sons of the children were 4th generation “on benefits” – this is not a gp problem… but a societal problem.
The gp is sometimes the patients only advocate…. and the truly vulnerable need protecting. But work needs to be made a priority within society.
We have forgotten that for rights to occur, we all need to have responsibilities. But that needs a societal shift!
i agree i would prefer long term sick notes to be done by an occupationally health trained doctor and i know we give sick notes to people who could do some form of work but it is difficult when faced with patient be it phone or f2f
Dr No issues sick notes on request and never on intimidation, being 6ft 4 and 110kg. I gave up pushing back on sick notes years ago. Firstly the workshy will just get one from somebody else (continuity of care etc etc) and secondly to spend the necessary time on discussing the therapeutic benefits of working inevitably adds another 10 minutes at least to the consultation. I’d rather see the next potential cancer case than try and save the feckless from themselves.