Research reveals GPs' role in absence management
Two new reports for the Department for Work and Pensions explore the way forward for the UK's flawed system of sickness absence certification.
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The role that GPs play in the management of sickness absence and return-to-work has been highlighted in recent years. Flaws in the current system of sickness certification have been identified by many of those with a professional interest, including employers and GPs.
Two new research reports from the Department for Work and Pensions (DWP) explore the area in great depth, providing a fascinating insight into the gap of understanding that exists between GPs and employers about each other's respective role in rehabilitation, a gap through which many at-risk employees fall.
Do GPs talk about work?
Generally, GPs do talk about work during consultations with patients on certified sickness absence, according to a study for the DWP1 of the approaches of 24 GPs to managing absence and assisting in return to work.
However, the approaches of individual GPs differ, as does the degree to which individual doctors engage with return-to-work issues. Although work is often seen as an intrinsic part of a patient's recovery, it is not itself always a focus of the GP's intervention.
Recently qualified doctors, and those with some occupational health (OH) experience, are more likely to be proactive and to see work as being part of a holistic approach to recovery. Yet less proactive doctors question whether managing sickness absence from work is part of their role, while some have a "clear view that it should not be".
The DWP report cited above explores the role that GPs play in managing sickness absence and their perceptions of the extent of their role in this area. It also provides insights into the types of discussions they have with patients, the factors that influence their approaches and how they work with other specialists and organisations.
The report was commissioned as part of the evaluation of the DWP job retention and rehabilitation pilots, a government-backed research trial that aims to test the effectiveness of health and work interventions to help people at risk of losing jobs (for example, those on long-term sick leave) to remain in sustainable employment. The pilots involved 2,845 people, and ended in March 2005. The main evaluation will be published at the end of 2005.
Given that the aim of the job retention and retention pilots was to help those still in work, but at risk of moving on to state benefits, it is perhaps surprising that there is only one small section in the study on GPs "liaising with employers". A separate chapter talks about joint working, but focuses on how GPs work with other agencies, such as Jobcentre Plus.
Work helps recovery
There is widespread agreement among GPs that work can be of therapeutic benefit in recovery for a range of physical and psychosocial reasons, but not in cases where patients work in low-paid or low-status jobs, or when work is a cause of the medical condition. The report finds that GPs' personal views about the value of work influence their attitude to rehabilitation and securing a return to work for employees.
GPs adopt a host of approaches to rehabilitation, from a holistic one that sees it as an integral part of medical rehabilitation, to one that focuses on medical rehabilitation, and views return to work as almost a by-product of medical interventions. The report identifies a number of constraints on GPs to becoming more actively involved in sickness absence management:
the doctor-patient relationship: this is of paramount importance to GPs, who sometimes perceive a conflict in their obligations to patients and the wishes of employers. The relationship is based on mutual trust and the patient's belief that the doctor is acting in their best interest, which means the doctor cannot take the employer's "side";
a shortage of time: this makes it difficult for GPs to address work issues thoroughly, an issue that is not addressed in the new GP contract which does not fund work rehabilitation activity;
limited OH expertise of most GPs: this hampers the giving of advice about the interaction between a patient's medical condition and work, and doctors have concerns about potential litigation; and
continuity: GPs face difficulties in providing continuity of care and building up an in-depth knowledge of a particular patient.
Fit or unfit?
In general, the DWP finds, a patient's work, or issues connected with it, do not influence a GP's clinical judgments about a patient, for example, decisions about referrals, the DWP research finds. GPs taking part in the study emphasised strongly that making clinical decisions on the basis of whether or not a patient is employed, or what sort of job they do, is wrong for equal treatment reasons.
Doctors assess fitness for work in a number of ways - some rely on the patient's own assessment, arguing that the individual is in the best position to provide this, while others form their own judgment by questioning the patient about their symptoms and work. Employees' motivation is a key factor in rehabilitation, and some of the GPs in the study use sickness certificates to manage patients' expectations and the timescale for a return to work, for example, by gradually shortening the duration of successive sick notes, or by warning patients that they are on their penultimate or final note.
The so-called "Med 3" forms - sick notes - are used by some doctors to inform employers that the patient is fit to return on a phased or part-time basis. However, other GPs are still firmly of the view that it is only possible to certify someone as fit to return if they are able to perform their full duties. GPs differ about whether or not they should be suggesting alternative work to a patient's employer, and express concern that their scope for doing so is limited if they do not have OH expertise.
Early intervention is crucial in securing a return to work, but GPs differ in terms of the point at which work is raised during discussions with patients on sick leave. The most proactive doctors (usually the most recently qualified) have detailed discussions from the earliest point, and also initiate contact with employers. The least proactive doctors undertake little or no discussion of work issues, and usually communicate with employers only as the result of the issue being raised by the employee, or in circumstances when the absence is "flagrantly illegitimate". In the middle ground lies a group of doctors who are quite happy to talk about work, but who stop if they meet resistance from the patient.
Talking to employers
The DWP study finds some evidence that the most proactive GPs have direct contact with patients' employers, either as a result of initiating it themselves or, "more usually", because they are approached by the employer. This group of doctors has written or spoken to employers in order to support patients, or have offered to do so. The contact involves talking about phased returns, or requesting special adaptations on behalf of employees. One doctor said he would like to continue talking once patients had returned to work to deal with any follow-up issues.
However, other GPs express concern about communicating directly with employers, preferring their patients to take the lead. They believe that direct involvement might become time-consuming and could breach patient confidentiality. Some believe that patients should take charge of this process as part of their return to work.
Doctors consider that their own OH expertise is limited and are concerned about giving bad advice, or that they have little to contribute to the world of work. Those GPs taking the narrowest view of their remit on sickness absence management see contact with employers as clearly outside the scope of their role.
Conflict of interest is a recurring issue for GPs in talking to employers, and all those involved in the research believe that their role is to act for the patient, not the employer. Some will reassure patients that this is their role, and show them any reports or letters before finalising and sending them to employers.
GPs are conscious that they are dealing with highly sensitive information, and some admitted to being very guarded or even cagey about what they write in letters to employers. They are also circumspect about giving too much information about a particular condition to an employer, for example, writing "depression" on a sick note. They will always give accurate information, but not detailed responses or suggestions.
Mixed experiences
GPs have very mixed experiences of working with employers and OH services. Some find them easy to deal with, and flexible and supportive of employees wishing to return to work. Others are less positive, believing that some employers resist phased returns, or act in ways that are otherwise inflexible. For example, the report finds that GPs see the fact that some of those on phased returns are not paid a full wage as "very unhelpful".
GPs suspect employers' motivations, believing they have hidden agendas and use the information provided by doctors "to get rid of employees". One GP, with more than 20 years' experience in a locality of medium deprivation, spoke of letters from employers that appear to be going through the legal hoops necessary to ensure a litigation-free employment termination for the patient after six months. "You never get the feeling from those letters that it's truly an altruistic gesture [from the employers]," the GP told the researchers.
Some employers, doctors believe, use sick leave to deal with performance issues, encouraging employees to go off sick to avoid disciplinary or capability procedures. OH departments are occasionally not seen to act in the patient's best interests, either by pressing for a quicker return to work than the GP thinks reasonable, or looking for reasons to terminate employment. Other GPs, however, report very positive experiences of working with OH services.
Improving relations
The research suggests some ways in which the working relationships between GPs and employers might be improved:
reinforce the evidence that work helps recovery, and stress the support available to those in low-paid jobs;
provide GPs with good-practice examples of joint working that does not breach confidentiality or jeopardise relationships with patients;
use sickness certificates to give employers more information, for example, use the "notes" part to talk about phased returns or other adaptations;
provide more OH training to support GPs in conducting fitness-for-work assessments or even "make such training a requirement for GPs to carry out sickness certification";
consider financial incentives to encourage GPs to take a more active role in sickness absence management: doctors currently consider that sickness certification is poorly resourced; and
remove the management of sickness from GPs and give it to specialist agencies: this might be supported by the least proactive GPs but, the report concludes, would not be consistent with the holistic approach to health adopted by the more proactive ones.
What next for sickness certification?
This latter option - removing absence management and sickness certification from GPs - is the subject of the second report for the DWP. It examines the potential for non-medical healthcare professionals to take on the role.
The report rules out removing certification completely from GPs, concluding that whatever replaces the currently flawed system will still involve GPs to some extent. It sees little scope for OH nurses to take on the job of issuing "Med 3s", including those based in, or working for, employers, and finds little support for the idea among the OH nursing profession itself.
The proposal to explore the feasibility of extending fitness-for-work advice and statutory certification to non-medical healthcare professionals was raised by the Cabinet Office Public Sector Team in 2001/02 as a way of managing the workload of busy GPs. The DWP Pathways to Work document also raised the prospect of widening the authority to provide fitness for work and certification to other healthcare professionals.
The current system of sickness certification is seen to be failing both employers and employees, and many GPs believe that it creates a conflict of interest between their role as the patient's advocate and their verification duties, threatening the paramount doctor-patient relationship. The report concludes that, in addition to piloting an alternative scheme, the existing scheme should be made to work effectively, reducing the workload on GPs in both the current, and any future, system.
The research does not identify a particular professional group to take on the responsibility of certification of incapacity for work, and finds varying degrees of support for the idea among the professionals themselves. For example, while 88% of osteopaths are in favour of taking on the job, only 28% of OH nurses support the idea. Those dealing with long-term illness and psychiatric conditions are least likely to welcome the extension to their roles, compared with those working with physical illness and acute services.
The report recommends a pilot study of alternative certification, but the government has given no commitment on this, saying instead that the findings of the research will be considered by the DWP in consultation with other government departments and professional bodies.
Two broad approaches for a possible pilot scheme are suggested (see box): one in which GPs conduct the initial consultation before passing the case on to other healthcare professionals, and a second where this sequence of consultations is reversed. The researchers conclude that the first option offers the most potential to build on positive aspects of the current system, at the same time as enhancing patient care and cutting GPs' workloads.
1Exploring how general practitioners work with patients on sick leave: a study commissioned as part of the Job Retention and Rehabilitation Pilot evaluation, DWP, 2005, research report no.257, www.dwp.gov.uk.
This article was written by Sarah Silcox, a freelance writer and trainer on employee health issues, sarahsilcox@waitrose.com.
