Moves are afoot to overhaul the GP-run certification system for staff on sick leave but there are doubts that the well-notes idea is the answer, writes Derren Hayes
If you’re looking for reasons why the government is keen on tackling what has been dubbed the UK’s “sick-note culture” consider these statistics: it is estimated that mental ill health caused by work-related stress costs the UK economy £8.4bn a year 36 million working days are lost each year because of occupational ill health and only half of those signed off sick with back pain for more than six months return to work.
The correlation between occupational ill health and poor life chances also makes for grim reading: suicide rates are 35 times higher among unemployed people than those in work those who claim incapacity benefit for at least one year are likely to stay on it for eight years and once you’ve been on incapacity benefit for two years you are more likely to die than work again.
Armed with these statistics, health secretary Alan Johnson signalled earlier this year the government’s intention to reform the GP-run sick-note system by shifting its emphasis away from what people can’t do to one that focused on the tasks they can perform. The financial incentives for doing this are obvious, but, according to Johnson, the approach is also underpinned by the philosophy that “work is generally good for people’s health”.
The Department for Work and Pensions is carrying out a review of the sick note – known as the medical certificate – with the intention of introducing a new system by next spring. In light of Johnson’s comments and recommendations from a review of the system by Dame Carol Black, national director for health and work, it seems certain there will be a major overhaul.
Black’s report, published in March, calls for the creation of a “well note” that would provide “practical advice to both the patient, and potentially their employer, about how a return to work can be achieved”. Better collation, analysis and sharing of information between the GP and employer on their patient’s/employee’s illness is also recommended.
The developments, following similar reforms to incapacity benefit, have prompted some disability and mental health campaigners to voice concerns that a system could be implemented that forces vulnerable people back into work when they are not capable, exacerbating their conditions.
“The rhetoric is good because it is strength-focused but the devil will be in the detail and the sector is suspicious [of the plans],” says Andrew McCulloch (right), chief executive of the Mental Health Foundation. “It will frighten mental health service users because there will be a sharper cliff edge between the deserving and undeserving.”
Guy Parckar, policy and campaigns manager at disability charity Leonard Cheshire, says, although the government’s arguments about the health benefits of work are “quite persuasive”, a system that has that ethos at its core could be too inflexible.
He says: “There are cases when someone has acquired an impairment and it’s not that easy to just carry on regardless as if nothing has happened. With this type of system you could be required to stay in work when it is not necessarily the best option for your health.”
Despite these concerns, many of these groups admit the system needs changing.
The regular criticism of the sick-note system is that GPs dish them out too freely. This has some credence – GPs lack the time and in some cases the skills to properly assess and diagnose certain conditions and come under pressure from their patients to issue them.
But John Canning, a member of the British Medical Association’s GPs committee, says it is not the doctor’s responsibility to police the sick-note system or to make decisions as to whether someone has to return to work. He believes GPs are being positioned as the fall guys by the government for the system’s failings.
Change in attitude
“Work is good for you and I would encourage [doctors] to talk to patients who have been off work sick about going back, but there is no point forcing people when they are not fit to do so. There are some people who don’t work when they could but equally there are some that at times work when they shouldn’t.”
McCulloch believes that GPs need a cultural and attitude change in the way they approach sick notes. For the new system to work it will have to tackle this, he adds.
“There are people who lapse into long-term unemployment unnecessarily. People can be disabled and very frightened by common medical conditions like depression, but if it is not properly treated and they are not supported they won’t get back to work.”
Part of the problem is the difficulty in obtaining support – in many areas patients may wait months for an appointment with NHS occupational or cognitive behavioural therapists.
Parckar fears shifting the system’s emphasis towards well notes could see GPs expected to become quasi OTs, “which they are not”.
Canning shares his concerns: “GPs can’t do workplace assessments which is what is needed. When it comes to a person with a stress-related illness I don’t know what they can do and what their employers will let them do.”
Most agree that the well note is just one part of the jigsaw. Improving links between employers and GPs is critical if measures to help those off work – such as phased returns and limited workloads – are to be successful.
McCulloch says: “We need a more strategic approach in primary care. Those with common disorders don’t just need a GP but input from social work, psychiatry and occupational health. You need a flexible approach – when I was off work my employer sent some work for me to do at home which helped retain links to the workplace.”
Most would agree that the current system is also too open to abuse, undermining those with a genuine need. Laws governing sick leave are complex and vary from employer to employer, with some paying full or part salaries for an unlimited period of sickness while others pay statutory rates or nothing. Eventually, though, most people on long-term sick leave move on to incapacity benefits.
Most to gain
Organisations – many of them in the public sector – with the most generous sickness policies have the most to gain from reforming the system. As one approved social work team leader at an authority in the South West says: “There are a lot of difficult situations with health and social care staff on sick leave. People with some forms of mental illness are protected and may not have an incentive to return to work. We mustn’t make it easy for people to access long-term sickness benefits without regular assessment.”
Contact the author
This article appeared in the 8 May issue under the headline “Signing off the sick note?”