Have sick notes had their day?

Alternatives to the current system of GP sickness certification are being piloted in the Midlands from this autumn.


LEARNING POINTS

  • General practitioners receive 22 million requests for sick notes each year, adding to the signifi cant workload that they face, and meaning they spend a relatively high proportion of their time doing a task that most of them readily admit they are poorly equipped to do.
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  • Employers criticise the current system, arguing that some GPs undermine their attempts at rehabilitation, or lack knowledge of workplace hazards.
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  • A pilot scheme to test nurse-led sickness certification has been launched in the Midlands, and will run until the end of 2005 before being evaluated in the following spring.
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  • Two models will be tested: one based on locally employed OH advisers located in the OH departments of large organisations; the other using advisers who will provide certification remotely from a call centre.

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    A debate has been raging recently about whether general practitioners (GPs) are the best people to certify sickness absence.

    Some employers argue that GPs hand out certificates too easily, while some doctors believe that the current system threatens to undermine their relationships with patients.

    The Department of Health (DoH), the Department for Work and Pensions and the British Medical Association (BMA) are establishing a series of pilots to examine alternatives to the current sick-note system. The largest trial is based in Coventry and Warwickshire, involving one major employer - PSA Peugeot Citroën - and a number of small and medium-sized enterprises. The Midlands project has funding from September 2004 until December 2004, and will be evaluated by the Department of Primary Care Studies at the University of Warwick in a report to be published in April 2006.

    The Midlands pilot will offer two types of nurse-led sickness certification - which largely replace the need for doctors to be involved unless a referral is necessary.

    In the first model, occupational health (OH) nurses from in-house OH departments (primarily PSA Peugeot Citroën, it being the largest employer involved in the pilot) will act as advisers and issue certificates.

    In the second model, employees of smaller organisations will be pointed in the direction of a call centre, staffed by nurses, who will provide telephone advice and certification on a remote basis.

    Nurse-led certification

    According to Dr Peter Holden of the BMA, who is heavily involved in the pilot, the two models have several objectives:

  • testing the feasibility of nurse-led certification in a range of enterprises - locally employed OH advisers in larger firms, and remote certification from nurse-staffed call centres for employees without access to in-house OH support;
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  • gauging the acceptability of the service among employees, employers and other stakeholders, and assessing take-up rates among employees;
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  • assessing the impact of the two models on sickness absence rates;
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  • identifying significant events from the perspectives of employers, employees and GPs;
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  • identifying the training needs of the new-style OH advisers and developing appropriate educational programmes; and
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  • surveying GPs, employers and employees for their views on the current sickness certification system.
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    Dr Holden described the operational philosophy of the pilot at the annual scientific meeting of the Society of Occupational Medicine (SOM) this summer.

    He said that job retention is the aim, where possible, and that this will require new approaches to rehabilitation, especially as technological change and shifts in the UK economy have led to the demise of the "light job" in many industries. The pilot scheme is designed to enable OH to be approached from the perspective of a person's fitness to work, rather than the current certification scheme, which tends to lead to the presumption that if a person is sick they cannot work, he added.

    Local GPs in the Coventry area are aware of the pilot and, therefore, know not to certify patients from PSA Peugeot Citroën, but send them to the company's in-house OH department. Notices are also being posted in GP surgeries advising workers from the company to visit their company's OH department. GPs and Local Medical Committees have signed up to the project.

    The PSA Peugeot Citroën model of OH support is being used for the local adviser model in the pilot, so that any employee off work, or who is expected to be off work, for more than seven days receives an assessment from an OH nurse. This assessment looks at medical information, the nature of the employee's job and the availability of alternative work, and examines the employee's need for investigation or referral - for example, for physiotherapy in the case of musculoskeletal disorders.

    The call centre model of remote certification is based on Swedish and US schemes, and provides nurse-led sickness absence management. Employees seeking advice and certification contact the OH advisers, predominantly OH nurses, by telephone, and they make a remote assessment of the case and manage it using a series of protocols. The OH advisers can also refer an employee contacting the call centre to an OH physician or their GP if necessary.

    According to Dr Holden, doctors do not need to be involved in certification because pre-pilot work at the main employer in the scheme provided evidence that OH nurses are suitably equipped to undertake the role. He adds that primary legislation is also not needed to enable non-GPs to complete sick notes.

    GPs: "back from the front door"

    Doctors need to "move back from the front door" and let nurses and other professionals take a greater role in sickness certification and wider aspects of workplace health, Dr Peter Holden believes. "After all, I don't expect to see a QC when I walk into my local solicitor's office," he adds.

    He challenges OH doctors with the following question: "Are you a skilled occupational physician offering added value to the organisation you work for, or are you an old-fashioned company doctor doing factory medicine for a quiet life, and an overhead?"

    GPs that get too involved in their patients' disputes with employers are starting to judge the case, according to Peter Holden. Also, a long-term relationship with a patient can easily be jeopardised if a patient is unhappy with the way in which a case that their GP was involved in is eventually resolved, he told the SOM meeting.

    One OH doctor at the meeting raised the case of a rehabilitation plan being drawn up for an employee by his organisation, being presented to the GP for information and comment, to be met by: "He's my patient, I know best - leave off."

    Dr Holden argues that GPs who insist on being advocates in this way should be reminded of the role of facilitating a return to work in meeting the World Health Organisation's defi nition of "health", which states that employability is vital to health. "The GMC [General Medical Council] should be interested if a GP is working against a person's full return to health by blocking return to work plans in this way", he added.

    Dr Holden has strong views about the current sickness certification system's failures, and believes that these can partly be attributed to a misunderstanding about the purpose of sickness certificates. He considers that sickness certification should be viewed as an absence management issue, not one for benefit offices or health services, as is the case currently, and that HR should be taking the lead. Sickness certification is a "nightmare" for GPs, he argues, as it is one of the few instances where it can be in the patient's interests to deceive his or her doctor.

    The current system has added to the workload pressures faced by GPs, who receive 22 million requests for sick notes every year. Doctors themselves consider that 25% of the average 577 notes they each sign a year are questionable, and that 20% are invalid. A total of three million employees admit that they would consider asking for a bogus note, according to research drawn on by Dr Holden.

    The new GP contract, which he was involved in negotiating, aims to remove the certification of absences of less than 28 days from doctors' responsibilities, and possibly even longer absences eventually. Dr Holden told the SOM meeting that the government is "utterly committed" to cutting bureaucracy, a resolve that dates back to a 2001 Cabinet Office Regulatory Impact Unit report on reducing GPs' paperwork.

    Other reasons why the current system fails, and why GPs are increasingly dissatisfied with it, include the arguments that:

  • it creates a conflict of loyalties: patients expect a GP to be their advocate in disputes with employers or the social security authorities, but GPs want to give facts, not opinions, and often believe they are drawn in to "referee" a claim;
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  • doctors need to preserve long-term relationships with patients, particularly in rural practices;
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  • the emergence of a complaints culture means that more gripes end up before the GMC, which can take years to clear a doctor in the event of a frivolous or even vexatious complaint; and
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  • GPs often have little knowledge of work, jobs or the hazards involved in particular industries and sectors, and are "bad" at certifying absence, according to Dr Holden.
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    He believes that a new system based on nurse-led certification will provide GPs with the opportunity to give "facts not opinions". Instead, GPs will be in the position to provide valuable information to contribute to the creation of a report on a patient's health by a third party, but not a sickness certificate. They will often be able to bring knowledge based on a long-term association with the patient.

    Success criteria

    The success of nurse-led sickness certification will be judged partly by its impact on participating employers' sickness absence rates, in particular, the duration of spells of absence. The pilot certification models will also be evaluated by their acceptability to all stakeholders, and by whether employees contacting either the local or remote OH advisers adhere to the advice given. All those using the nurse-led certification schemes will be contacted by telephone three days after advice is given to assess this aspect of the scheme.

    This article was written by Sarah Silcox, a freelance writer and trainer on employee health issues, sarahsilcox@waitrose.com.


    SOM shorts: disclosing chronic illness at work

    Employers should introduce policies and procedures to encourage employees with chronic illnesses to disclose them, according to Dr Jehimidah Munir, speaking at the annual scientific meeting of the Society of Occupational Medicine (SOM) this summer.

    The rise in mental ill-health cases at work, and the fact that it is often impossible for employers and managers to offer help to retain people in work unless they chose to disclose mental ill health, makes this study of the factors influencing disclosure timely. Help is usually only possible if employees choose to disclose their health status. This decision is influenced by perceptions of discrimination from colleagues and managers, the illness's visibility and the adaptations it might require.

    Just over a quarter of people in a study of higher education organisations conducted by Dr Munir disclosed their chronic illness to line managers, and this was most likely for those with depression or anxiety. The likelihood that they would receive support from colleagues and line managers was the most important factor determining disclosure, followed by the employee's own experience of the illness. People with diabetes were most likely to disclose their health status, while academics constituted the occupational group least likely to disclose because they have the flexibility to manage their condition by working at home. Those disclosing asthma or musculoskeletal conditions were most likely to receive physical adjustments at work, while those disclosing depression or anxiety were least likely to receive such adjustments, the study concludes.

    Contact: jehimidah.munir@nottingham.ac.uk.