‘The sick note’: A qualitative study of sickness certification in general practice in Ireland

Abstract

Background: Sickness certification is a common task undertaken by General Practitioners (GPs) in most developed countries. Research suggests that they find this task complex and difficult. Primary health care structures and sickness certification practices differ across Europe and little research explores GPs certifying practices in the Republic of Ireland.

Objectives: The aim of the study was to explore GPs’ views on sickness certification, the strategies used to issue sickness certificates to patients and scope for improvement in the current system.

Methods: A qualitative thematic approach used one to one in-depth interviews with 14 individual GPs, across 11 primary health care practices in Ireland. Analysis of the data was conducted using NVivo 8 qualitative software.

Results: GPs can find their role as certifier problematic, and a source of conflict during the consultation process with patients. GPs were concerned with breaching patient confidentiality and in particular disclosing illness to employers. They reported feeling inadequate in dealing with some cases requesting sickness leave, including certification for adverse social circumstances. Sickness certification was often given in response to patient demand. GPs felt a need for better communication between themselves, employers and relevant government departments.

Conclusion: This study highlights the various complexities and challenges that GPs face when dealing with patients requiring sickness certification. Issues in assessment of fitness for work and problems within the social welfare structure were recurrent themes. The study highlights the opportunities to improve the system and how these might be achieved. Further research is now warranted in Ireland.

Key words::

• General practice
• epidemiology public health
• sickness certification
• sickness absence

KEY MESSAGE(S)

• Issuing a sickness certificate to a patient may be influenced by the medical and social welfare structures. Improving the system requires significant engagement with employers and social benefit agencies.

• Focus should be placed on referral and rehabilitative pathways for patients to ensure appropriate certification and early return to work.

Background

The increase in certified sickness absence found in most European countries during the last decade is of increasing concern to public health agencies (1–3). While sickness absence can promote rest and recovery from illness, it may also have negative consequences, including increased risks of inactivity and isolation, poorer quality of life and increased use of health services (4–6). In the Republic of Ireland (ROI), sickness certification is part of General Practitioners’ (GPs’) contractual service to the Department of Social and Family Affairs (DSFA) (Supplementary Box 1 available online only at http://informahealthcare.com/doi/abs/10.3109/13814788.2012.672967). Sickness certificates are also issued to patients as evidence of illness for employment purposes.

Sickness certification is associated with important social and economic issues (6–9). Reported figures for 2008 suggest that the cost of illness related benefits to the taxpayer in Ireland is in excess of 22.5 billion. In this period 10% of the total working population claimed benefits; 73 609 people received sickness benefit, 53 725 received invalidity benefit and 95 752 disability benefit (10). Although entitlement rules differ across the European Union (EU), these figures compare to working age population sickness-related benefits claims of 9% in Sweden, 7% in Denmark and 7% in the UK (11). In 2006, Ireland's total social protection expenditure in paid sickness leave and medical costs accounted for 41% of total social benefits and was 11% higher than the EU average (12).

A recent systematic review implies that sickness certification requires GPs to fulfil multiple roles, which may cause difficulties and conflict in their position as doctors (13). Common occupationally related conditions, such as musculoskeletal and mental health related problems are thought to pose particular difficulties for GPs in the certification process (7,14). GPs must often rely on the patient's own assessment of functional capacity to work (14,15). In addition, concerns have been raised about the skills of doctors in managing fitness for work, their knowledge of a patient’s working tasks and their understanding of the certification system (16). It is thought that GPs may learn about occupational tasks through second-hand knowledge provided by the patient and the process of sickness certification is learned through a system of trial and error (14,17). Some GPs in the UK have implied that they would like to remove the task of sickness certification from their practising role (18).

There is a paucity of research that explores the process of sickness certification or GP attitudes to sickness certification in an Irish context (19). The aim of this study was to explore GPs’ views on sickness certification practices, the strategies used to issue sickness certificates to patients and scope for improvement in the current system. The study was conducted as phase one of a larger mixed method investigation of sickness certification practices in the ROI.

Methods

A qualitative approach using one to one interviews was adopted for this section of the study so that the topic of sickness certification could be probed in depth by the researchers. Preliminary qualitative research is considered valuable when the subject matter is new, underdeveloped or complex and where there is a need to compile appropriate dimensions or questioning for larger quantitative studies (20).

Waterford Institute of Technology and the University of Manchester Research Ethics Committees granted ethical approval in 2009.

Participants

The study was conducted in eleven primary care practices across the Republic of Ireland between February and June 2009 (Box 2). The sample population was initially drawn purposively from the Medical Directory of Healthcare Professionals. The selection process was based on the year of graduation, gender and geographical location (urban/rural) of the GP. A letter detailing the study was sent to thirty GPs as an invitation to participate in the study. A telephone call followed. 6 of the 30 GPs agreed to participate, 7 refused and 17 did not respond. 4 GPs were recruited following an article in a national newspaper and a further 2 as a result of a GP conference. A further 4 GPs were contacted by letter, 3 accepted but 1 was unable to participate because of a patient emergency. 14 GPs took part in the qualitative interviews. 2 were still on the GP registrar programme and, therefore, still in training, but were not excluded as they were working and certifying in general practice. As soon as ‘theoretical saturation’ was reached, no further GPs were recruited.

Box 2. Socio-demographic data of participating GPs.

Gender

Male (n = 9); female (n = 5)

Postgraduate qualification in occupational medicine

Yes (n = 7); no (n = 7)

Practice location

Urban (n = 5); suburban (n = 4); mixed (n = 4); rural (n = 1)

Practice size (small < 2000) (medium = 2000–8000) (large = > 8000)

Small (n = 2); medium (n = 8); large (n = 4)

Number of years as GP

Registrar programme (n = 2); 6–10 years (n = 3); 11–15 years (n = 3); 16–20 years (n = 2); > 20 years (n = 4)

Contact hours

Full-time (n = 11); Part-time (n = 3)

Interviews

The participating GPs were interviewed using an interview schedule developed from issues identified in the literature (Box 3). The interview guide was piloted with two GPs prior to the main interviews. All interviews were conducted by the main researcher and these took place at an arranged time in the interviewees’ own place of work. Written consent was obtained along with demographic information before each interview began and discussions were audio digitally recorded. Each interview began by asking the GP to give their initial thoughts about sickness certification and topics were then raised in turn following the interview guide. Aspects of sickness certification brought up by the participant were probed in more depth by the researcher. At the end of each interview, GPs were asked to reflect and add any further comments in relation to sickness certification. Interviews lasted between 25 and 40 minutes.

Box 3. Main interview topics.

• GPs’ thoughts on sickness certification

• How GPs’ felt about the task of issuing sickness certificates

• Discussion of a recent consultation that involved giving a sickness certificate, Doctor initiated/patient requested?

• Difficulties experienced by GPs in sickness certification

• Discussion of the GPs role when issuing sickness certificates

• Strategies GPs used in issuing sickness certificates

• Supports for GPs and patients; and scope for change

• Discussion on occupational related illness presenting within primary health care

• GPs’ views on employers and their handling of illness in the workplace

Data analysis

Analysis was conducted using NVivo 8 qualitative software. The main researcher transcribed interviews throughout the process of data collection. Each transcript was read and re-read to obtain an overview of the data and to identify any further points of interest that required exploration in the subsequent interviews. On completion of all interviews each interview was coded into the main categories from the interview guide. The content of each of these categories was re-coded into broad themes using the process of simple thematic analysis (21). Interpretation of the narratives was decided on through negotiated consensus among the researchers. Finally, through a process of discussion each theme was agreed. Eight major themes were identified from the data.

Results

Theme one—GP's role in sickness certification

The question of how GPs viewed their role in the issuing of sickness certificates was raised during the interviews. All 14 GPs agreed that the role of a GP in sickness certification is to act as an advocate for the patient. GPs were keen to acknowledge that their role was not a policing role for employers or to act as gatekeepers for patients in receipt of social welfare illness related benefits.

“We are doctors, we are there to get people better, we are not policemen for the state or department of social welfare and we are not there to police (GP2).”

Theme two—conflict in sickness certification

GPs believed that the vast majority of patients who required certification appeared genuine. However, all participants indicated conflict in sickness certification over the course of the interview. GPs described the pressure to provide sickness certificates when they were not entirely comfortable to do so. This type of sickness certification was most commonly associated with the patient's adverse social circumstances, for example, caring for a sick child or other family member. Several GPs spoke of the structure of primary health care in Ireland and implied that they were often torn between business pressures and certification practices. If GPs were too rigorous in certifying a patient, they were concerned it would affect the doctor-patient relationship and that patients may move to a different practice. All GPs spoke of the internal conflict they felt when sickness certification was required for a problem that had limited measurable or demonstrable pathology. Further conflict in roles was described by 3 GPs in relation to the structure and level of sickness absence payments for patients and the financial incentives for GPs in continuing to certify these patients as unfit for work.

“If you have built up a relationship with a patient then it is difficult to refuse a sick note in tragic circumstances (GP2).”

“You are often between a rock and a hard place, you have a duty to society, …, like if I was too hard on certs they would just go down the road to the competition, we are mindful of that and we try and do a balancing act (GP3).”

“This state certification is another area where somebody is out of work because of a particular condition and entitled to social welfare, it’s how to get them off that band wagon afterward can be difficult … there may well be an incentive for GPs to continue certifying for the state because there is a fee each time (GP10).”

Theme three—patients and disclosure

The issue of patient confidentiality was an important concern for GPs. The opinions of the participants were mixed for disclosure of illness to an employer. 3 GPs claimed they took a conservative approach and said they would never disclose an illness, while the remaining 11 felt it was meaningful in some cases to inform the employer. All GPs showed some concern about breaching patient confidentiality and who might have access to the information on the certificate. 5 GPs highlighted concern about disclosing illness of a psychiatric nature to an employer and worried what affect this type of illness could have on a patient in the workplace.

“In the short term pieces of paper (non-state) … well that system is nuts because we are sending out letters to people that are not medical and there is a huge confidentiality issue (GP14).”

“Most of the time I will write it down, if its a physical illness, if it’s a psychiatric illness I would not write that, if it was work related stress I would write that with the patient's permission (GP4).”

Theme four—supports for GPs in practice

GPs described several stakeholders in the sickness certification system including patients, employers, DSFA, medical assessors, specialists and other colleagues who were certifying in an occupational capacity as independent company assessors. All GPs expressed a level of dissatisfaction with supports provided to help in fitness for work cases and mentioned the lack of resources in prevention and rehabilitation services. GPs, with the exception of one, described the relationship between GPs and the DSFA as ‘non-existent.’ Although guidelines were presented by the DSFA and a medical review system was in place, most GPs stated that they never had any contact with the DSFA or the medical assessors and only received information when they had requested a case to be reviewed. 4 GPs seemed unsure of the actual process in referring a patient to the medical review board for a second opinion or how they operated in their review of long-term certified patients. GPs acknowledged that referral to specialist occupational physicians was an option available to them but that if the public system was used there was frequently a long wait, which they feared might lead to a more chronic patient sick role. There was unanimous agreement that the main support for GPs in sickness certification was through interaction with other GPs. This was often facilitated through the Continued Medical Education (CME) Network.

“DSFA …, updates, nothing, no feedback, no dialogue what so ever … and the only link is the medical referee in the middle … we never hear, see, know what they look like, know what they are thinking (GP10).”

“It's kind of vague all right there are examinations to make certain decisions and check the genuineness of it. I am not really clear on whether I initiate that or whether the social welfare board call them (GP12).”

“In our continuing education forum we have the ability to discuss difficult cases, one time we found that a guy went to one doctor looking for a cert and he didn't get it, it turned out that he had gone to two or three in the group until eventually he got one (GP3).”

Theme five—training and education in sickness certification

Several GPs highlighted the lack of occupational training at undergraduate and postgraduate level. The 7 GPs trained in occupational medicine were keen to point out that occupational medicine training had given them a good insight into the area of sickness certification. 1 GP who was involved in GP training commented that training in occupation medicine was something that could be improved but this was ‘complex’ and other factors required consideration such as the congestion in the GP training curriculum and the structure of primary health care. Both participants on the GP registration programme felt ill prepared to issue sickness certificates and one stated that there was ‘no emphasis at all on certification in training.’

Theme six—strategies for issuing sickness certificates

All GPs stated that the sickness certification system was patient driven and that the patient usually initiated the conversation. The responses from GPs suggested the strategy for issuing a sickness certificate was dictated by the patient's request to be certified.

“Usually the patient (asks for a cert), sometimes I would ask if they needed one (GP2).”

“I do think it a bit of both, people come in and its their agenda and they do need a cert and that is what the whole consultation is about, and there are some people that don't want to take time off work even though they are sick. It's more often generated by the patient as they need them now for employment reasons (GP14).”

Other strategies included giving the patient the benefit of the doubt when they presented with limited measurable pathology. GPs cited patients who they felt were comfortable in the sick role and happy to be claiming benefits. GPs used various strategies to cope with extenuating social circumstances and would often certify a person as ‘stressed’ when they had to care for a sick relative. One GP said that they would attribute a child's illness to the parent and certify the parent as suffering from the child's ailment.

“The longer I am in practice the more likely I am to say that they (the parent) are suffering and I put down whatever the child is suffering from, if the child has an ear ache I will put down that the patient is suffering from an ear infection, because they are (laugh). If you think about it, by extension they are suffering (GP11).”

Theme seven—scope for change

All GPs acknowledged that there was a need for change and a review of the current system. One GP commented on the need to be reminded of the ‘implication of certification.’ A number of suggestions were put forward to improve the current system including a regulated self-certification period similar to that in the UK and other European countries and the facility for other professions to certify in shorter-term illness. By contrast, two GPs raised concerns about changing the current system and made reference to Irish society.

“I am a great believer and I think that if you can generate honesty transparency and trust of an employee for a company then self certification has to be the way to go, medical certification in my opinion is somewhat abused in Ireland ... I don't know about the Irish mentality though, the Irish love something for free and while there is no evidence to back this up that is my personal opinion not a professional one (GP1).”

“Self-certification I don't know, not in the Irish society we live in at the moment (laugh), the question is who the self-certification thing would go to and who is going to judge that. I think it would be very problematic (GP14).”

GPs were asked if the sickness certification process could be improved if patients were required to register at only one practice and did not have the freedom to shop around. They all replied positively and that all patients should have ‘their usual doctor.’

Some of the comments suggested the need for change in the state sickness certification system. The changes deemed necessary were to the administrative aspects of sickness certification, to guidelines concerning examination rules, fitness for work criteria and certification periods.

“Again, a number of people on long term disability, they probably couldn’t go back to the work that they are doing, but I wouldn't see them never working again and I think that its a real shame, so what you are getting at is are they fit to work or unfit to work … yes that needs to be changed (GP7).”

Theme eight—employers, attitudes and practice

When asked about the type of occupational illnesses that GPs most frequently deal with in primary healthcare, musculoskeletal and psychological problems were the two types of condition that were most frequently mentioned.

“Things that occur as a result of workplace or are aggravated by the work place, hazards, most common, musculoskeletal and soft tissue issues. Occupational stress is something that we are seeing a bit of (GP5).”

GPs spent a proportion of the interview discussing their views of employers. While it was felt that GPs have a certain amount of responsibility to the employer, several of the participants expressed the opinion that employers were responsible for some sickness absence because of the policies and practices that operated in their workplaces.

“The other side of it is that many employers have a situation set up like a sick pay scheme where somebody has to produce a piece of paper justifying their absence or I have seen in some situations where somebody has to be out for three days before they get something on the sick pay scheme (GP5).”

In some cases parents of sick children asked the GP to certify them as the sick person as they were unable to take uncertified time from work to provide care. GPs thought that such a system was inflexible and did not offer alternatives to employees who were unable to attend work for reasons other than sickness. One GP commented that such situations should be 'better facilitated by employers.’ Other GPs suggested that happy employees resulted in healthier employees. Comments reflected the opinions of some GPs that the links between them and employers could be improved in the interest of patients.

“Communication could be an awful lot better ... the GP does not get any background or information on the person's job description or how they are managing at work, recent changes, how often they have been out of work … you need as much background as possible to be as helpful as possible.… The better the communication the better the outcome (GP6).”

In contrast, one GP thought that it was not the function of GPs to engage with employers;

“If there is a company medical advisor in place, I think the 2 doctors can control the volume of communication. I think if you bring the employer in, the employer's skill set is centrally associated with the work process in a lot of respects is not skilled or effective in meaningful communication with doctor (GP8).”

Another felt that communication with employers could be beneficial, but could prove to be difficult;

“The primary relationship is between the GP and the patient … sometimes you can have the employer ringing the GP without the patient's knowledge requesting information about the issuing of certs, that can be difficult with the risk of breaching patient confidentiality (GP2).”

Concerns were raised about the limited knowledge GPs had in relation to the working tasks of patients. Such deficiencies rendered difficulties in decision making related to fitness for work. It was acknowledged that larger organisations were proactive in occupational issues and usually employed an occupational doctor to assess fitness for work. Comments reflected a view that such a system should become a requirement of all organizations.

“I think that every company by law should have a company doctor.... If you are really serious about cutting down on absenteeism and improving the general health of your workers that would be the way to go (GP3).”

It was suggested that fear of litigation could influence employers negatively. GPs thought that some employers might not wish to allow a claimant into the workplace while compensation procedures continued.

“That's a huge issue … when litigation is complete; when the process is complete, often back pain will improve … I suppose if you focus on neck and back pain it's going to be worse…. I think it would be wonderful to have a staged return to work; some employers are less understanding and won't give somebody a less physical task (GP7).”

Discussion

GPs acknowledged their role as advocate and their professional responsibilities in the provision of sickness certification. While they expressed the view that a high proportion of sickness certification was genuine and did not present difficulties for them, they were concerned with aspects of the current system. These included difficulties in assessment of fitness for work, lack of resources in prevention and rehabilitation, lack of training in occupational medicine, problems with employers and employment practices and lack of contact with the DSFA. In addition, they were concerned with lack of flexibility in the system and concerns about possible breaches of patient confidentiality. GPs incorporated various strategies for dealing with sickness certification, including waiting for a patient to ask before offering a sickness certificate, certifying a person as unfit for work when in fact somebody else was sick and giving the patient the benefit of the doubt without measurable pathology. GPs shared the view that scope for change exists in the current system in Ireland.

Strengths and limitations of the study

The GPs interviewed were from several different counties in Ireland. The sample characteristics included a representative mix of GPs in respect of their age, level of experience and gender. Good levels of consistency were found between the experiences of participants and, therefore, it may be assumed that an acceptable level of data saturation was reached (22). Sampling bias may have resulted from the selection of participants; it is feasible that this study represents those who had a particular interest or strong views in the topic. 7 of the 14 participating GPs had some formal occupational training and may have a greater insight into the relationship between work and health. Therefore, the results may not fully reflect the views of all GPs practising in Ireland. Two systems of sickness certification are currently used by GPs in Ireland. We have not always distinguished between the two in this study. Both systems run concurrently and we did not explore whether one system has an influence on the other and subsequently if this impacts on GPs’ attitudes to certification.

Comparison with existing literature

These results are consistent with those of European studies that found conflict between being a patient advocate and managing the professional role as ‘judge’ in fitness for work (7,13,18) . GPs in the present study suggest that sickness certification may be required solely to preserve the ‘doctor–patient relationship,’ for example when they are faced with a 'difficult’ patient or placed under 'pressure’ to certify. Such motivation was indicated as one of the main reasons for issuing sickness certificates to patients in two previous UK studies (8,18).

Strategies for dealing with aspects of sickness certification were described by several GPs in our study; for example providing a sickness certificate on a patient's request or avoiding the discussion about certification and fitness for work. The development of individual strategies for dealing with aspects of sickness certification is not uncommon and has been described in other European studies (14,15,18). Findings from studies focusing specifically on fitness for work consultations suggest that ‘fitness for work’ is not always fully explored in the consultation (23,24).

The term ‘fitness for work’ was perceived by GPs in our study as ‘unclear’ and open to various interpretation and they were often unaware of the working tasks of patients. They stated that they commonly accepted the patient’s word in assessing their functional ability in the workplace. Similar difficulties have been identified in several studies conducted in the UK and Scandinavia (15,16,19). In the UK, a new 'fit note’ has been introduced to attempt to tackle this problem. The 'fit note’ aims to focus on what working tasks the patient can do rather than what they cannot (25).

Based on our study results GPs commonly certify for psychological problems, a finding consistent with those of other studies (8,30). This certification may be related to GPs’ perception of employers, stigma associated with psychological related problems or absence of support for patients who remain in the workplace. Patient confidentiality and disclosure of illness to employers was one of the matters of concern for GPs. It is unclear what evidence Irish GPs have to draw upon in relation to this aspect of sickness certification and further exploration is warranted.

GPs in Ireland may be under additional pressure to maintain high patient loads to ensure business viability, thus there may be motivating factors for GPs to certify patients when they are not entirely comfortable to do so. They are paid for each sickness certificate issued by the DSFA. The conflict between payments for GPs in sickness certification versus encouraging return to work is not widely discussed in the literature. However, the role of financial incentives in driving behaviour in general practice has been seen in other areas such as childhood immunization and fund holding schemes (26,27). An analysis of data preceding the implementation of the GP fund holding scheme in the UK implies that GPs respond to financial incentives in practice (27).

Statistics show that illness benefit case referrals to medical assessors dropped by 45% between the period of 1998 and 2007 (28). The reduction in referrals may be related to some factors including the lack of collaboration identified between GPs and the DSFA or the structure of the reimbursement scheme operated within the Irish system. There is evidence that several patients opt out of being assessed by the DSFA when called for examination, for example in 2007 31% of patients called for a medical review chose not to attend (28). Explanations for such behaviour include the use of sickness certification for non-medical reasons such as social or domestic problems.

The GPs in our study were open to changes in the current system and suggested a regulated system of self-certification as they felt that employers were driving the criteria for short-term sickness certification. While such a change may bring some regulation to the Irish system, it is unlikely that it would remove the more complex problems that occur in the sickness certification process. The UK and other European countries offer a regulated system, but have similar problems in decision-making, assessment of illness and interpretation of guidelines relating to fitness for work (13,14,29,30). However, regulation might lessen the workload for short-term self-limiting illness and give patients greater autonomy. Recommendations for a better system of referral for patients, support for GPs and greater contact with the DSFA were conveyed by GPs in our study. Some of these findings concur with those of a study, which examined the sickness certification process in Sweden and a recent systematic review on GPs’ feelings in sickness certification (13,31). GPs in our study felt improved interaction with employers on sickness certification could lead to better outcomes for all; the employer, the patients and the doctor. A recent UK study suggests GPs rarely engage with employers on work related issues and under these arrangements a lack of engagement results in unrealistic expectations in managing their role as certifier (32).

Implications for practice and future research

It is feasible that the primary health care and social welfare structures in Ireland impact on the certifying practices of GPs. GPs appear disgruntled and frustrated by aspects of the sickness certification system. It appears that sickness certification may be influenced by the nature of the presenting problem, the social circumstances of the patient, or by the patient's demand. Many of the discussion points raised by GPs in the interviews raise the hypothesis that some regulation is required for the purpose of ‘proof of illnesses’ for an employer, as it represents a source of conflict for them and may breach the core ethics of patient confidentiality. Further research should explore the area of ownership of sickness certification data and its disclosure in greater depth. There is a perception among GPs that employers are using non-state sickness certificates as a management tool in controlling absenteeism. If so, then future collaboration between primary health care and employers is required to resolve this issue. Focus should be placed on rehabilitation pathways and other alternatives to allow patients to remain within the workforce.

The 7 occupationally trained GPs in our study were unanimous in the view that they had a greater insight into the relationship between work and health. Such a finding may be important and may suggest that consideration should be given to training in occupational health for GPs who certify in general practice, especially in relation to advice relating to the workplace and sickness absence.

Conclusion

This research demonstrates that GPs face many challenges and complexities in sickness certification in day-to-day practice and that these problems are similar to those identified in other European studies. A review of sickness certification in Ireland is now warranted and should take place within an epidemiological framework to establish a baseline for further research and policy generation.

Acknowledgements

The authors acknowledge the contributions of all the GPs who willingly gave up their time to participate in this study.

Declarations

Funding: None

Ethical approval: Waterford Institute of Technology and the University of Manchester Research Ethics Committees

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.