Abstract
Background Sickness certification constitutes daily clinical practice for GPs. In April 2010, the UK sickness certification system changed to reflect the evidence that work is generally good for health and a new Statement of Fitness for Work — the ‘fit note’ — was introduced. Sickness certification is a contentious topic among GPs and the proposed fit note generated mixed reviews.
Aim To explore GPs' views and use of the fit note during its first year of operation.
Design and setting Qualitative interview study of GPs based in different geographical locations across the UK.
Method GPs (n = 15), who were recruited from a national sample, participated in semi-structured telephone interviews which were subject to constant comparative analysis.
Results Overall, the fit note was well received. GPs recognised that work is generally good for health and felt the fit note facilitated using an earlier return to work as a negotiation tool. GPs perceive employers as the major obstacle to early return to work. There were reports of scepticism towards the system that negatively impacted on some GPs' operation of sickness certification. Feedback over the fit note's impact on employer behaviour and the return of a mechanism that enables GPs to request early independent assessments would be welcomed.
Conclusion A revised approach is needed to address the scepticism towards the sickness certification system that persists among some GPs. New strategies need to be designed to engage employers in facilitating an early return to work and to enable the objectives of the medical statement reforms to be achieved.
INTRODUCTION
Work is generally good for health and wellbeing, and absence from work is generally detrimental.1 For people with ill health, the benefits of remaining in, or returning to, work are equally significant, with the relationship between health and work universally recognised as integral to the prosperity and wellbeing of individuals, their families, workplaces, and wider communities.2 For those unable to work due to ill health, sickness certificates provide supporting evidence for health-related benefits claims;3 GPs certify short- and medium-term sickness absence under their NHS terms of service.4 During an average week, a full-time GP will sign approximately 10 certificates;5 consequently, sickness certification constitutes daily clinical practice.
In April 2010, the sickness certification system changed. A strategy on health, work, and wellbeing was introduced to change the predominant national philosophy that illness is incompatible with work and to reflect the evidence that work is generally good for health.2,6 A Statement of Fitness for Work was created (the ‘fit note’) to focus on helping people return to work.3 The fit note sets out four options — phased return to work, altered hours, amended duties, and workplace adaptations — for doctors to consider in order to assist with back-to-work discussions between individuals and employers; however, employers are not legally bound to implement suggestions made for work amendments.3
The fit note aims to reduce bureaucracy for doctors by merging some of the previous sickness certificates and abolishing others.3 The shortened time period between submission of a claim for state benefits and independent assessment of fitness for work has eliminated the need for a mechanism enabling GPs to request an independent assessment.7 The fate and function of previous sickness certificates is outlined in Table 1. The generation of more clinical time is intended through sanctioning telephone consultations as an acceptable form of assessment and removing the requirement for doctors to certify fitness to return to work.3,7
Managing a consultation about fitness for work requires skilful negotiation and the practice of certifying sickness absence is a contentious area among GPs.8 Research has demonstrated that some GPs value their participation in this process and feel they are best placed to fulfil this role,9 while others would like their certification role removed.9 Prior to its implementation, the fit note attracted mixed reviews. Some argued that GPs are best placed to complete fit notes, with their ‘unique position to provide patients with evidence-based advice about their work’, while others stated that ‘GPs are not, and will not become, the police of the benefits system’.10
Sickness certification stakeholders include patients, clinicians, employers, and policy makers; each has its own set of drivers within the sickness certification process. Set in this context, this study aims to evaluate GPs' views and use of the fit note during its first year of operation to explore whether further actions are required for the fit note to achieve its objectives.
How this fits in
GPs certify absence from work due to illness as part of their daily clinical practice. However, some GPs would like to relinquish their role, and some view the sickness certification system with scepticism. To date, it is not yet known how GPs view and use the reformed medical statement. This study found that the fit note has positively influenced practice in encouraging an early return to work but, despite the reforms, scepticism persists among some GPs. GPs agree with the philosophy behind the fit note and view employers as the limiting factor towards achieving the fit note's objectives.
METHOD
Recruitment and sampling
In total, 125 GPs were randomly selected from a list of 397 GPs who, during previous research, consented to receiving further contact and study invitations.11 An information pack including participant information leaflets and consent forms was posted to them. Non-responders were sent a reminder after 2 weeks.
Purposive sampling was subsequently employed to select 15 GPs from the 26 who consented to participate. Participants were selected on the basis of demographics that were thought to influence perceptions and experiences;12 practice location, practice list size, duration of service, postgraduate occupational health qualifications, contract basis (partner, salaried, locum, full time, or part time), and sex were considered.
This study formed part of a larger project that required 15 GP participants; as such, 15 GPs were interviewed and included in this study; two GPs worked at the same practice. Interviews were undertaken between August and November 2010.
Data collection
The topic guide used broad prompts to explore key issues emerging from the literature. Semi-structured interviews, lasting 30–60 minutes, were undertaken by one researcher. GPs were interviewed via telephone (n = 10 in practice, n = 5 at home). Consent was obtained for study participation, interview recording, and quotation use, and interviews were transcribed verbatim.
Analysis
Data analysis was continuous and iterative to enable emerging themes to surface. Thematic analysis was undertaken using constant comparative methodology,13 facilitated by NVivo 8 (QSR International, Doncaster, Victoria, Australia). The first transcript was independently read, re-read, and coded by two researchers. The initial codes were discussed and revised where appropriate. These codes were applied to a second transcript, followed by discussion and comparison across these first two datasets. Any discrepancies in coding were discussed until consensus was reached. The emerging coding frame was applied to the remaining transcripts by a single researcher. Themes were compared across participants (complete dataset) and within individual accounts to understand them within context.
RESULTS
The sample comprised six female and nine male GPs. The time these GPs had worked in general practice ranged from 5 years to 32 years (median 21 years). Eleven GPs were partners, three were salaried, one worked as a locum, 10 were full time and five worked on a part-time basis. Practices were located in cities (n = 5), towns (n = 7), and small towns (n = 3); approximate practice list sizes ranged from 2600 to 15 500 patients. Three GPs had occupational health specialist training.
Five themes emerged around GPs' views of the fit note and its role in decision making during the consultation. No new themes emerged after 14 of the 15 interviews. Demographic variables did not appear to influence opinions towards one viewpoint.
Changing philosophies and clinical practice
All GPs recognised the philosophy that work is generally good for health and some discussed their changing perception of sickness certification:
‘I think I actually prefer the fit note I have to say, erm, because it, it sort of, you start off with the assumption that, you know, we're trying to get back to work rather than the assumption of er, you know, we're not trying to get back to work, erm, you know, we're just trying to find a way for you to manage on, on an inadequate income and not work. Erm, so yeah, I quite like the concept of the fit note.’ (GP 661)
‘As regards qualifying the ability of someone to return to work, then I feel it's been a step forward and … I'm happier signing sick notes now than I was in the olden days … I feel that the note has a different role. It can now act as a sort of “Let's try you back at work and see”, erm, whereas I think both myself or GPs and patients regarded it as a “You're off or you're fully back”.’ (GP 760a)
These responders emphasised that the fit note facilitated a positive approach, empowering them to engage the patient regarding health rather than sickness.
Some GPs described how the fit note had changed their practice, reminding them to discuss the merits of work with ill health and enabling them to provide more support for patients in complex situations. Other GPs felt the fit note had not changed practice because they were already encouraging a return to work:
‘I think it must — it might make people think about, you know, the way they can get back, you know, people back to work, which is a good thing. I mean, I like to think that I was thinking that anyway.’ (GP 304)
There were no negative perceptions towards the underlying philosophy of the fit note. However, one senior GP (GP 345) felt the reforms had a negative impact on his work, stating it was difficult to change a ‘lifetime of practice’.
Negotiation facilitator
GPs described how the work amendment options printed on the fit note raised their awareness of working with ill health, leading to negotiations with patients at earlier stages in their illness. The printed options provided a visual aid that also assisted negotiations:
‘And I think for some GPs it probably raises their awareness of, there is the option of amended duties or short hours and stuff … it just sort of makes it more at the top of my mind if someone asks for a fit note. I have this instant reminder that I should maybe challenge the patient's assumption that they need to be off sick. And it certainly makes it easier to negotiate with the patient, you know, there are, I can sort of say, you know, there are these options, which your employer can be asked to consider … I can, I can gently challenge them. I think it has made a big difference because I think it opens up those options more.’ (GP 387)
Having the return-to-work options explicitly displayed in a tick-box format lent an ‘authority’ to the fit note. Some GPs found that it provided an official influence over their discussions with patients and between patients/employers:
‘… I think patients believe that they're going to be … it's going to be taken notice of more because it's all printed on the certificate and I'm ticking to say that that's got to occur. I think they feel a bit more authority to that …’ (GP 760a)
Efficiency
GPs described how the fit note has impacted positively and negatively on their work efficiency. Responders reported that amalgamating previous sickness certificates has reduced the bureaucratic burden of appropriate form selection and has eliminated confusion over the array of certificates that existed previously:
‘No, I'm glad to get rid of Med 5, sorry, Med 4. FMed — sorry, FMed 5. The pink one. Erm, I'm delighted to have got rid of that one. Er, and sometimes I think I was the only person in the universe who ever completed it. Er, pers— my patients when they wonder “what's this?” Erm, but I've always used it for retrospective rather than post dating, actually, er pre-dating, er, FMed 3s. FMed 4 I don't mourn the passing of whatsoever. Er, it was a total pain …’ (GP 345)
The ability to use telephone consultations to assess fitness for work rather than face-to-face consultations was welcomed. GPs described this as a more efficient use of time for both themselves and patients. One GP was particularly enthused and estimated the daily clinical practice impact:
‘You know, we have the patients who toddle in after a week off poorly just for us physically to clap eyes on them to issue them with a sick note for 3 days. And they know they didn't need to see a doctor and we know they didn't need to see a doctor. And being able to do it over the phone has made a huge difference … I would guess 20% are being dealt with … but, of the, particularly the shorter-term work, I would guess one in five has been dealt with over the phone.’ (GP 760b)
Although the fit note has removed the need for a medical statement confirming fitness for work, the new system appears to be misunderstood by patients and employers, who persist with such requests. GPs recounted patients consulting primarily to obtain a certificate declaring fitness for work, citing both employer and patient-driven expectations for the request.
Sickness certification system limitations
GPs identified obstacles to the fit-note objective, which appeared to originate from discrepancies in driving forces behind stakeholder activity. Participants stated that continuing to allow employers to determine work capability undermined the function of the fit note in facilitating a return to work:
‘Well, you know, it's — the idea of graded return and things like that, you know, is fine and yes, it is good to see it appear on the new sick notes. But, you know, we're not in a position to impose. It's largely words written on water because there's no obligation on the employer to take up on the suggestions you make.’ (GP 757)
GPs recounted patients experiencing difficulties with employers while negotiating an amended work return. The general perception was that, although patients were motivated, employers were often unable to accommodate amended positions and those who had the capacity to support an early return were already providing this:
‘[Patients] come back saying, “Well, they [employers] took one look at the sick note, ‘phased return’, and said, “Well, no you can't really. When you're back, you're back.” That, that's what I'm told by my patient anyway. And just a, a few occasions since they came out in April, erm where they've, erm, sort of come back later on and said, “Well, that phased return never worked. I asked if I could do just mornings for the first week and they said, ‘Well, no. That's just not possible with the way the place works”.’ (GP 760a)
‘[I'm] slightly unsure how much difference it makes me doing that [writing amended duties]. I mean those things have been, I think, particularly with bigger employers, that sort of thing has been happening anyway.’ (GP 760b)
These excerpts convey the frustration that GPs face in their efforts to encourage a return to work.
One GP cited the gap between policy making, the drivers of the Department for Work and Pensions, job centres, and the reality of everyday healthcare as an important contributor to the negative perceptions and scepticism that some GPs hold towards sickness certification system changes. Another responder described how failure to engage GPs during the fit note introduction had widened this gap:
‘So it's not … however it's been set up, this new system with the fit note and all this razzmatazz, it's sort of missed the essence of getting GPs on board with it, the job centres on board with it.’ (GP 145)
Although only two responders raised concerns, this negativity has a potentially significant impact on the fit note's ability to achieve its objective.
One responder described the sickness certification behaviour that had been witnessed while visiting practices:
‘And then I'd have to say that I saw, the other day, a doctor signing six fit notes for patients he had not seen um, that a nurse brought in. So it's obviously not respected, not in my practice, when I was out at another practice.’ (GP 145)
This reported GP behaviour, perhaps arising from underlying negative perceptions towards the sickness certification system, seems to be limiting the fit note's capacity to achieve its objective of shifting the focus towards assisting those with ill health in their return to work.
Further actions
Responders described how the bureaucratic burden could be further reduced by reminding employers that there is no legal obligation for GPs to certify fitness for return to work. Some also felt there was a lack of training for GPs around sickness certification; others, however, thought further training was unnecessary because sufficient training material was available and accessible, but that time pressures and the low priority of sickness certification restricted its use:
‘Erm, I'm finding a few difficulties with it [the fit note] … I'm finding it difficult to know what to put on this new fitness note. I probably could look it up in, there's an online site that I could look at, but time is of an essence — you tend to just look at what's available.’ (GP 554)
One GP described a misunderstanding of the revised system by other agencies, highlighting the need for further education:
‘And even when it first came out and I filled it in correctly, I then had a couple of them sent back to me, I think by the job centre or something, but they were wrong, so they hadn't had the training in it.’ (GP 145)
Responders felt training for other stakeholders might improve the fit note's function in supporting early work return, but held differing views towards the benefits of further GP training.
GPs discussed how feedback on the impact of their certification suggestions would be useful for clinical practice evaluation:
‘I don't quite know whether it works, if that makes sense. I don't quite know what happens when it lands on an employer's desk when they haven't been thinking about that kind of stuff … Whether they look at it and go, “I've got to do this” or “What does the doctor mean?” or just ignore it or whatever.’ (GP 760b)
Six responders felt the withdrawal of the RM7 was detrimental to them balancing their role as patient advocate with statutory duties. The RM7 was used to temper conflicting roles and helped to preserve therapeutic relationships in cases of disagreement over fitness for work:
‘… the one thing that would help me a lot is if there were some independent agency that I could consult about this, erm, if I had doubts about a patient on long-term sickness for example, erm, and could … if we had the equivalent of the old RM7 form, where we could get a patient seen, erm … that would allow GPs who had doubts about their, about their patient's fitness to work or otherwise, to get an independent [assessment] because that would get over this issue. I also said right at the beginning, which was that we — it's difficult for us to, erm, go against our patient's wishes because we have to go on having a relationship with them as their doctor and their advocate in the future.’ (GP 321)
The function of the RM7 seemingly extended beyond a simple request form and is missed by GPs.
DISCUSSION
Summary
Overall, the fit note was well received. GPs recognised that work is generally good for health and felt the fit note was an effective negotiation tool in facilitating an earlier return to work. The revisions have reduced ‘unnecessary burdens’ but employer requests for certification of fitness to return to work are preventing optimal efficiency.
Employers were seen as the major obstacle to an early return to work and there were reports of scepticism towards the system, which negatively impacted on some GPs' operation of sickness certification. GPs were aware of available learning resources but the low priority of sickness certification and restricted time meant access is limited. The GPs in this study felt that feedback over the impact of the fit note on employer behaviour and the return of an RM7-like mechanism would be welcomed.
Strengths and limitations
To the authors' knowledge, this study is the first to explore GPs' views and use of the fit note during its initial year of statutory operation. The interview time period may mean problems identified by GPs, including the request of a return-to-work certificate, will improve with experience.
GPs with a range of experience, work patterns, and geographical location were interviewed ensuring a spread of opinions was captured. The different demographics did not appear to influence findings towards one viewpoint. The relatively small sample did mean there was a risk of GPs with alternative views being overlooked, but no new themes emerged after 14 interviews.
The interviewer's occupation — as a GP trainee — was disclosed before interview commencement. Interviewing one's peers is considered both a strength and a limitation. Prior topic knowledge and associated professional cultures enables a thorough exploration of the subject without explanation seeking and terminology clarification;14,15 in addition, solidarity between professionals may encourage disclosure,16 particularly in research addressing sensitive areas, including sickness certification. However, prior subject knowledge may prevent researchers from finding novel insights within their data17 and being interviewed by a colleague may induce cautious responses for fear of judgement.18 A heightened awareness of these issues and frequent reflections within the research team limited this potential influence's impact. Interviews were discussed with non-medical research team members to ensure no presumptions were being made by the medical interviewer and to ensure that important ideas were not overlooked throughout the interviews.
Concerns over the ability of telephone interviews to foster rapport and recognise more subtle nuances of non-verbal communication have been raised.19 However, in this study, telephone use enabled a degree of anonymity, thereby noticeably encouraging responder participation in a topic that some may consider to be a sensitive area.
The findings have been derived using a single methodology. Limited time and resources meant a triangulation process was not undertaken. Considerations must therefore be given to the possibility of alternative research methods yielding different study findings. This study provides a basis for future research, particularly as the fit note becomes embedded into daily practice.
Comparison with existing literature
The use of the fit note to facilitate negotiations confirms previous research findings regarding a trial fit note.20 A survey of UK organisations found only 51% of businesses provided changes to work patterns or environment, or offered flexible working to support the return to work after a short-term sickness absence.21 An independent report into workplace health identified GP concerns over lack of employer support in occupational health issues.22 GPs in the current study held similar views, by identifying employers as the major obstacle to achieving an early return to work.
The interviews revealed a hint of scepticism among GPs towards the sickness certification system and some witnessed GP behaviour that perhaps indicates that the system is not universally respected. Previous research found that some GPs deliberately misused sickness certification as a result of their frustrations with a system they perceived to be fundamentally flawed.23 While the current study does not demonstrate that GPs are deliberately misusing the system, it seems the negative perceptions persist despite the recent reforms.
Although some research suggests GPs desire further sickness certification training,11 this was not universally the case in the current study. These findings reflect those of Hiscock and Ritchie, who found little enthusiasm among GPs for highlighting sickness certification as a formal part of postgraduate training9 and Cohen et al, who identified sickness certification as being of low training priority.8
There is little research exploring use of the RM7 and the recent consultation process on medical statement reforms does not specifically discuss GPs' views towards its withdrawal. Hiscock and Ritchie found that the RM7 was used inconsistently by GPs, with some being unaware of its existence and some electing to stop completing it because no action appeared to result from its use.9 The current study has demonstrated a novel finding: that the RM7 was primarily used to balance conflicting responsibilities within the consultation.
Implications for practice and research
The fit note is prompting a change in GP behaviour towards encouraging an early return to work. However, the ongoing scepticism and low priority of sickness certification must be addressed if the fit-note objectives are to be achieved. Alongside further training, providing GP feedback could be useful. With the imminent introduction of the electronic fit note,3 this may be possible at individual and national levels. The return of an RM7-like mechanism would reduce perceived role conflicts and, consequently, lessen some GPs' negative views of sickness certification.
The fit note has reduced some unnecessary burdens for GPs. However, further work with employers is required to reiterate that a ‘fit-for-work’ statement is not required for Employers' Liability Compulsory Insurance reasons.6
The forces that drive policy makers, clinicians, and employers in their management of sickness absence differ and this needs to be recognised to design a flexible system that will engage employers towards facilitating an early return to work. The government-commissioned review into the UK sickness absence system aims to maximise flexibility for employers and employees.24 This offers an opportunity to develop new strategies to engage employers and, ultimately, achieve the objectives of the fit note and the health, work, and wellbeing strategy.
Acknowledgments
We gratefully acknowledge the GPs who participated in the study and the GPs who provided advice on the topic guide.
Notes
Funding
The study was funded through the National Institute of Health Research (NIHR) Academic Clinical Fellowship held by Victoria D Welsh and forms part of the NIHR Programme Grant for Applied Research (RP-PG-0707-10131-Optimal management of spinal pain and sciatica in primary care). The views and opinions expressed within this article do not necessarily reflect those of the NIHR. Christian D Mallen is funded by an Arthritis Research UK Clinician Scientist Award.
Ethical approval
Study approval was granted from the North Staffordshire Research Ethics Committee (reference number: 10/H1204/10).
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
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- Received August 24, 2011.
- Revision received October 10, 2011.
- Accepted December 6, 2011.
- © British Journal of General Practice 2012