Family Practice Advance Access originally published online on February 2, 2008
Family Practice 2008 25(1):20-26; doi:10.1093/fampra/cmm076
Sickness certification in the general practice consultation: the patients’ perspective, a qualitative study
Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
Correspondence to: Kathryn O'Brien, Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK; Email: obrienka{at}cf.ac.uk
Received 16 March 2007; Accepted 3 December 2007.
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Abstract |
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Background: Up to a third of general practice consultations involve issuing sickness certificates. Recent research has looked at the GPs' perspective of sickness certification but there has been no in-depth research exploring patients' views of these consultations.
Aim: To explore patients' views of sickness certification within general practice consultations, and how these could be improved.
Methods: A qualitative study was carried out with 12 general practices in South Wales; interview study of 19 patients who had recently received a sick note from a GP.
Results: Patients rarely attended just for a sick note, more often wanting advice or an opportunity to ask questions. Patients valued continuity of care, a good doctor–patient relationship, adequate consultation time and discussion about their illness, social situation and work-related issues when consulting with their GP for a sick note. Many patients felt doctors did not have enough time or knowledge of the patient to the able to address this issue adequately and this increased feelings of anxiety. Patients did not feel that being questioned by their GP or discussing return to work threatened the doctor–patient relationship.
Conclusions: GPs who simply give out sick notes without question or discussion are not necessarily giving the patient what they want. More time should be spent discussing work and illness-related issues. Policy makers should recognize that continuity of care a good doctor–patient relationship and adequate consultation time are important to patients and any initiatives aimed at GPs to improve return to work rates should take these into consideration.
Keywords. Consultation, doctor–patient relationship, occupational health, patient-centred care, qualitative research, sickness certification.
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Introduction |
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The socio-economic cost of sickness absence is vast with 2.7 million people of working age currently claiming incapacity benefit in the UK.1 The high levels of sickness absence are also a problem in other Western countries, with significant cost to employers, insurance companies and society.2 The cost at the individual level also needs to be considered. It is well recognized that being in work is beneficial to health.3 The longer a person remains off-sick the less likely they are to return to work and this in itself can have a detrimental effect on health.1,4
In much of Western Europe and in the USA, doctors have a central role in sickness certification. In the UK, doctors have acted as gatekeepers to the benefit system since the 1911 National Insurance Act and the beginning of the welfare state. Although all doctors in the UK can issue sick notes, the majority are issued by National Health Service GPs.2 An international review conducted by the UK Department of Work and Pensions (DWP) found that most countries have similar systems to the UK, with sickness absence verified by a doctor (usually the GP) following a short (variable) period of self-certification.2 The most notable difference is the Dutch system where certification and medical treatment are separate; self-certification is used to claim sick pay and occupational health care physicians contracted by the employer are involved in rehabilitation and verification of sickness. Although there are some differences in other sickness certification systems, the challenges facing doctors involved in the process are often similar.2
International data suggest that between 9% and 35% of all GP consultations involve issuing sick notes.5,6 In the UK, GPs have estimated that sick leave is discussed with between one and six patients per session (half-day).7 GPs find consultations involving sick notes problematic.5,7,8 They often perceive that there is a conflict of roles, which may place pressure on the doctor–patient relationship.7,8 There is a perception that patients ‘doctor-shop’ until they find someone to simply give them a note.7 Many GPs issue certificates on demand, some stating patient advocacy as the priority and others feeling it is simply quicker to give the note rather than enter into discussion.8,9
Most of the published research concerning sickness certification and sickness absence is from Sweden, Norway and the UK. Research has mainly focused on the GPs’ perspective.7–11 We found some studies which have considered sickness absence, sickness-related benefits and some aspects of certification from the patients’ perspective.12–17 However, these did not explore patients’ views of consultations concerning sickness certification in depth. Exploring patients’ views and concerns are important factors in other medical consultations, and it has been shown that this can significantly influence outcomes.18–20 It is not known how patients feel about consultations concerning sickness certification, and in particular whether they see them as any different to other consultations or if they share the view of many GPs that these consultations are often unsatisfactory.
Governments and employers are keen to reduce sickness absence rates. If GPs are to be encouraged to revise their approach to sickness certification, while maintaining a good relationship with patients and acting in their interests, it is important to base any changes on a clearer understanding of the patients’ views.21 The aim of this study was to explore patients’ experiences and expectations of sickness certification consultations with their GPs, using qualitative methods.
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Method |
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We conducted a qualitative study based on semi-structured interviews with patients whose recent consultation with their GP had resulted in sickness certification.
Using a sampling frame of all practices in South East Wales, practices were purposively sampled to represent inner city and suburban areas and the South Wales Valleys (ex-mining communities with high levels of deprivation) and to include training practices, multiple partner, single-handed and Local Health Board run practices. We employed this sampling strategy in order to explore the experiences and views of a wide variety of patients.
Seventeen practices were approached, sent information about the study and subsequently contacted by telephone. Twelve agreed to recruit patients. GPs were asked to give out study information packs to the next 10 patients they issued with a sick note (med 3, med 4 or med 5) for any reason. Two hundred and eight recruitment packs were issued to GPs over the study period; however, it is not known if all these packs were given to patients. These packs contained an information leaflet, letter to the patient, consent form and stamped addressed envelope. GPs were asked to exclude patients who they felt were too ill to participate or who were unable to give informed consent. Patients were asked to return the consent form with their contact details to the research team if they were happy to participate in the study. In view of the potentially sensitive nature of this research question, we asked GPs to emphasize to patients that participation in the study was optional, confidential and not related to their benefits or employment in anyway. Patients who completed consent forms were then contacted by one of the researchers and an appointment made for an interview at a place of their choice.
Data collection and analysis
Semi-structured, face-to-face interviews were conducted, audiorecorded and subsequently transcribed verbatim. The interviews were carried out by either KO or NC between December 2004 and January 2006. Both interviewers also work as GPs, but this was not disclosed to patients unless they specifically asked, and only one of the participants asked this at the end of an interview. Practices where the interviewers have previously or currently work clinically did not participate in the study.
An interview guide was developed through discussions between all researchers. The interview guide covered background information and topics felt to be most relevant based on a review of the literature and the researchers’ own experiences. Interview questions focused on the social, work and illness context, reasons for consulting with the GP, attitudes and feelings prior to, during and after the consultation, length of time and diagnosis on the sick note and relationship with the GP. The interview schedule provided a guide; however, participants were encouraged to talk about topics which were important to themselves allowing thematic ideas to emerge from the data. Topics which were raised by respondents were incorporated into the interview schedule for exploration in later interviews. A summary of the final interview topic guide, which underwent iterative revisions during early data analysis, is provided in Box 1.
| BOX 1—Topic headings of the interview schedule.
Description of the area, social setting and illness. Considering the last time that you saw your GP about being off work, how did you feel before you saw your GP? When you actually saw the GP, how did you feel that went? Did the GP give you a sick note? What was on the note? Was this what you were expecting? Who did you feel made the decision about being off work? Do you feel there is any difference when you see your GP for a sick note compared with other times? Was there anything that you would have liked done differently? Do you think that this consultation will have any effect on future consultations? How do you think your experience compares with others? Is there anything else that you think I've missed or that you would like to tell me?
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Interviews were transcribed by a research secretary and checked by NC or KO. Following transcription, each researcher independently identified emergent themes and constructed a coding framework. The final framework was developed by discussion between NC, KO and FW. A qualitative software programme, Nudist6, was used to assist with coding, sorting and retrieval of data. An inductive approach to analysis was used, allowing thematic ideas to emerge from the data. Thematic content analysis was conducted in parallel with data collection.22,23 A coding frame was developed for the main concepts, which were then broken down further into subcodes creating a hierarchical coding tree. Data collection continued until the researchers were satisfied that thematic categories had become saturated and no new themes emerged. This was when 19 interviews had been conducted. Reliability of the analysis was maintained through independent coding of 20% of the data by more than one researcher, and any ambiguities in coding were resolved by discussion among the researchers.
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Results |
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Twenty-six patients returned consent forms. Two returned forms had insufficient contact details and five patients subsequently withdrew. The 19 interviews lasted between 20 and 70 minutes. Table 1 shows the characteristics of the participants.
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Six main themes emerged from the analysis of the interviews: ‘a doctor who knows me’, ‘a doctor of my choice’, ‘I need time’, ‘what I want from the consultation’, ‘what I want on the note’ and ‘who decides if I am sick enough?’
A doctor who knows me
Many participants felt high levels of anxiety prior to a consultation in which they wanted a sick note, and this was heightened by seeing a different doctor. Continuity of care was important to them and the desire to see the same doctor was particularly strong for consultations involving repeat sickness certification (Box 2). These were seen as more personal consultations than those about an acute illness. Participants talked about the importance of doctors knowing them and knowing their history (both social and medical). They commented on problems associated with seeing different doctors and locums. They reported feeling that doctors who did not know them gave them shorter consultations. Having to repeat their history was perceived as wasting time. Frustration was expressed about doctors not reading the notes and familiarizing themselves with the patient's history prior to the consultation. Participants with psychological problems found it particularly distressing and stressful having to repeat their stories time and time again. One woman felt that continuity was so important, both for herself and her family, that she would not change doctor, even though she was not satisfied with his communication skills.
| BOX 2 A doctor who knows me.
Patient 17: Female, 36–50 years, valley locality, chronic psychological illness ‘I had to explain it all again and I do get very upset and of course [usual GP] would know because she'd seen me before and seen me in the situation and she'd know’. Patient 10: Male, 36–50 years, urban locality, chronic physical illness ‘I would rather stay with the same doctor because he knows about my case (...) If it's just an odd thing like flu or something I would see any doctor then. I don't mind then, it's not a problem’.
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A doctor of my choice
Participants expressed clear reasons for wanting to see certain doctors and avoiding others. These centred on a sense of rapport, trust and feeling listened to (Box 3). Participants who felt they had a good relationship with their GP saw them as their advocate in the sickness certification system and spoke positively of their encounters. They spoke of being aware of the doctors' gate-keeping role in the benefits system but did not perceive this as a threat to their relationship and trusted the doctors to act in their interests. This contrasted with the views of most of the participants who had been in contact with occupational health or personnel departments. In these cases, the emphasis was generally felt to be on checking up, discipline and meeting the employer's interests rather than those of the patient. Appointment booking systems and access issues made it difficult, at times, for patients to see their choice of doctor.
| BOX 3 A doctor of my choice.
Patient 18: Male, 20–35 years, urban locality, chronic physical illness ‘well, more personal, more friendly, just generally, not like me the boss, you the patient’. Patient 5: Male, 36–50 years, urban locality, acute physical illness ‘you get the odd doctor that will say how're you feeling, and you know it's just chit chat, as opposed to actually listening to what you are saying ... there are a few that seem genuine and will listen to what I'm saying’.
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I need time
Some participants felt that less time was given in consultations primarily involving sickness certification than in other types of encounter. Time was valued by participants, and giving time was linked with being a ‘good’ doctor and satisfaction with the consultation (Box 4). Many commented that doctors’ workloads seemed too high and they felt their consultations suffered as a result.
| BOX 4 I need time.
Patient 12: Male, over 50 years, valley locality, chronic physical illness ‘He had taken time to listen to me and discuss the implications, and to sort of get my life back on track’. Patient 4: Female, 36-50 years, urban locality, chronic physical illness ‘I'm in there about 10–15 minutes usually, having a chat about different things, and I ask what I want to ask—I don't feel as if I'm being rushed to get out of the room’.
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What I want from the consultation
For almost all the participants, the consultation had many purposes and was not solely about obtaining a sick note. Participants were very aware of abuses of the system and the GP's need to ensure that sick notes were genuine. Many clearly stated their desire to be questioned, and their illness fully understood by the GP (Box 5). Most expressed a fear that they may be perceived as playing the system and felt the need to prove that they were genuinely ill. This was a particular concern for those with illnesses which were not visible, such as back pain and depression. The need for a sense of understanding from the doctor seemed greater in these participants. A need to prove they were genuine was expressed even by participants who were certain that they could not work regardless of the doctor's opinion. They wanted validation not just for themselves but to prove to work, family and wider society that they were genuinely not fit for work. Validation of their sick role was only felt to take place when the doctor had sufficient knowledge of their symptoms and viewed these in the context of other issues in the participants’ lives.
| BOX 5 What I want from the consultation.
Patient 1: Female, 36–50 years old, valley locality, acute psychological illness ‘he didn't ask any questions, so to me he doesn't really know why I'm on the sick. He wrote it down, but he doesn't really know’. Patient 2: Female, 36–50 years old, valley locality, acute psychological illness ‘I've basically said I don't feel well enough, please can I have a paper [sick note], and he hasn't discussed with me how I feel about going back to work or whether I feel like going back to work, you know, nothing has been discussed at all’. Patient 10: Male, 36–50 years old, urban locality, chronic physical illness ‘I might go in and say I've got hand pain just to try and get a week off. Can he question that? He must be thinking have I or haven't I? I might not be suffering with it. I think with a lot of them he's got to try and read between the lines’.
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Participants wanted to talk about medical issues such as their symptoms, treatment options and prognosis or have specific questions answered. The few who said they had been to the GP solely for a sick note were generally receiving regular medical advice and support from another source, for example from secondary care or medically trained friends or family.
What I want on the sick note
Some participants wanted to have an input into what was written on the note in terms of the diagnosis while others felt that this was up to the doctor alone (Box 6). There were concerns about the implications of specific diagnoses on the certificate. For example, one woman was worried that having ‘stress’ on the certificate, and on her personnel records, would have an impact on future employment opportunities. Another respondent wanted a clearer diagnosis and more information on the note to reflect the severity of his condition and its impact on his life.
| BOX 6 What I want on the sick note.
Patient 13: Male, 36–50 years old, valley locality, chronic physical illness ‘he said he will give me a note for a month, I thought that was a long time. I didn't want to be off from work for a month, but then he did alter it to two weeks. As it turned out though the month would've been okay but it just frightened me. I suppose I didn't like the sound of that’. Patient 7: Female, 36–50 years, valley locality, chronic physical illness ‘I think he should've put his foot down with me. I think he should've said no really that's not enough time, because that would've helped me at the time because I think I felt under pressure [from work]’. Patient 16: Female, 36–50 years, urban locality, chronic physical illness ‘they don't put much information on it and I think that's probably better and I don't necessarily want the office to have a massive description of my problems either...’.
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The experience of most participants was that the doctor determined the length of time on the certificate. Many felt that this should ultimately be the doctor's decision, often assuming that the doctor would know the prognosis of their illness and therefore the amount of sick leave needed. One woman expressed frustration that the doctor had not told her at the beginning of her illness how long she was likely to be off work for. Others also felt that some discussion about the duration of sick leave would be helpful early on in the illness. Most patients welcomed some discussion about the duration of the sick leave. However, a few felt uncomfortable if the doctor asked them how long they wanted written on the note.
One participant commented that the doctor needed an understanding of what the work entailed in order to determine whether he could return to work or not. Others talked about wanting guidance from the doctor about when they might be ready to return to work. Those who expressed feelings of guilt about not being in work spoke of the doctors persuading them to take time off or even ‘telling them off’ for considering going back to work.
Who decides if I am sick enough?
Participants had very different views about who should make the decision about being off work (Box 7). Approximately a quarter felt ‘the doctor knows best’. They would do whatever the doctor suggested regardless of how ill they felt. They wanted a passive role within the decision-making process and saw doctors as the experts. About another quarter said they could not work regardless of the doctor's opinion. These tended to be participants with physical problems. The remainder were less sure and wanted to have input into the decision but not sole responsibility for it. Participants seemed less satisfied with the consultation when the doctor failed to take on the role the patients wanted within the decision-making process.
| BOX 7 Who decides if I am sick enough?.
Patient 14: Female, 20–35 years old, urban locality, acute psychological illness ‘I would rather the GP said, right, you're off, and then it's not on me to decide or convince anyone that I'm ill. I've got a piece of paper to say, look, she's ill, she needs this amount of time off ... but if the GP felt that I didn't need one [sick note] or I didn't need time off work, then I would say fine, I'll go back to work ... I'm looking up to them to be the expert and for them to tell me not to work rather than me deciding that’. Patient 3: Female, 36-50 years old, valley locality, chronic physical illness ‘It's you, you know yourself how you are feeling. You are aware of your own wellbeing and how you are actually feeling at the time. If you're not up to it, you're not going to go back are you?’. Patient 13: Male, 36-50 years old, valley locality, chronic physical illness ‘He asked me what I did and where I worked, the type of work I'm doing and it was obvious to him in the end that there was no way that I could actually do the job at that time’.
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Discussion |
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Summary of main findings
Patients want the same from consultations involving sickness certification as they do from other general practice consultations, despite many GPs seeing these consultations as different.8 Patients value continuity of care, time and comprehensive discussion in consultations involving sickness certification. In our study, participants wanted the opportunity to discuss being off work with a GP who knew them and could place their sickness certification in the context of their illness, work and home life. The desire for discussion was evident even in those patients who were adamant that they could not work.
Strengths and limitations of the study
The subject matter addressed in this research is very sensitive in nature. Response rates were low despite us asking GPs to emphasize the confidential, independent nature of our research to potential participants. We do not have any information about the characteristics or views of non-responders. However, the participants did come from varied social and geographical settings and covered a spectrum of physical and psychiatric illness. The low response rate does not devalue the accounts of these participants, who gave us detailed information about their experiences of the sick note consultation. All our participants felt justified in their sickness certification but we could speculate that some of the non-responders did not. As with all interview studies, participants may have chosen to present a ‘public account’ of their views and opinions which would reflect them in a favourable light.12,24 Although the research was conducted just within Wales, we believe that the findings will be of use to practitioners in other countries as most countries have similar systems of sickness certification to the UK.
Comparison with existing literature
Studies exploring the views of GPs have found that GPs often regard consultations involving sick notes as quick consultations. Some GPs have expressed the view that with time pressures in busy surgeries "it is easier to ‘just sign’ than enter into a lengthy discussion".1,9 We found that participants had experienced this but wanted more from these consultations. Other studies have shown that time and continuity are important to patients and associated with greater patient satisfaction, enablement and clearer plans for the future.25–27 This study has shown that these issues are particularly important to patients in consultations involving sickness certification. The DWP initiative ‘Pathways to work’ has improved return to work rates by addressing the physical, psychological and social barriers faced by patients.28 Our study indicates that the majority of patients value discussion about these issues and want information and discussion about their illness, prognosis and work, rarely attending solely for a certificate. Both Hussey et al. and Hiscock and Ritchie found that GPs recognize the importance of knowing the patient and spending time with them when using strategies for challenging or negotiating with patients about certification or alternative options, although they often felt that they were endangering the doctor–patient relationship.8,9 Participants in our study did not feel threatened by discussion about sick leave when this took place in the context of a good doctor–patient relationship.
Implications for clinical practice and future research
GPs need to consider the potentially high cost to their patients as well as to society of failing to handle these consultations effectively. The negative consequences for the patient of being out of work and trapped in the sick role include poor mental health, poverty and social isolation.1,29–31 Wessely suggests that sickness certification can be thought of as an intervention with risks and benefits.4 By discussing the pros and cons of being off work, the consultation can become a process of shared decision making. Our participants demonstrate that, as with other decision-making encounters, doctors will need to be flexible and respond to the needs of the individual patient. Some patients will want to take on an active role, while others will need more guidance from their GPs when making these important decisions. Our study findings have strongly influenced the clinical practice of the clinical researchers (KO and NC). Prior to this study, neither clinician spent much time discussing work issues, believing that patients generally just wanted their sick note signed and nothing more. Now both clinicians spend more time in consultations concerning sickness certification exploring patients’ concerns and plans regarding work and their illness and sharing decisions about diagnosis and timing.
More research is needed, particularly in considering the interaction between patients and GPs during consultations involving sickness certification. This was an area which was also highlighted by a review of sickness certification practices in 2003.11 The level of shared decision making in these encounters could be explored further particularly in the area of patient involvement in the choice of diagnostic term on the sick note, when sick leave should be granted and how long the certification should last. This research indicates that levels of patient participation in decision making in these areas are low. An observational study of videoed consultations concerning sickness certification would further understanding in this field. Associations between key components in the consultation and outcomes such as patient satisfaction and return to work rates could be explored.
When considering initiatives aimed at reducing sickness absence, policy makers should take into consideration the importance to patients of continuity of care and adequate consultation time with their GPs, to allow exploration of the complex issues surrounding sickness certification. This may be challenging in the context of recent changes in general practice and the UK government's long-term plans for reorganization in primary care.32
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Declaration |
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Funding: Cardiff University.
Ethical approval: South East Wales Research Ethics Committee (04/WSE02/112).
Conflicts of interest: None.
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Acknowledgments |
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We thank all the patients who took part in the study, the GPs who helped with recruitment and Amanda Iles for transcription of the interviews. We also thank Glyn Elwyn, Debbie Cohen and Mansell Aylewood for commenting on an earlier draft of this paper.
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Notes |
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O'Brien K, Cadbury N, Rollnick S and Wood F. Sickness certification in the general practice consultation: the patients’ perspective, a qualitative study. Family Practice 2008; 25: 20–26.
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References |
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