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Just say no to sick note requests

Fit notes are just a way of GPs shirking their responsibility for deciding if a patient is too sick to work. Far better to robustly refuse dubious requests, just as GPs do in France, says Dr Alexandre Fuzeau

Fit notes are just a way of GPs shirking their responsibility for deciding if a patient is too sick to work. Far better to robustly refuse dubious requests, just as GPs do in France, says Dr Alexandre Fuzeau

It's not hard to find an example of an unjustified sick note. Take the numerous people signed off with back pain and depression. In France, where I am from and where I worked as a GP before moving to the UK, patients signed off for back pain really have back pain, and those signed off with depression really are depressed.

Over here, I was puzzled to see so many people getting sick notes for back pain when they had stiffness, but normal and apparently pain-free mobility, and for depression, even though they had no sign of neglect or suicidal intent. Indeed, many of these patients were suddenly no longer depressed if they got their sick note, and positively argumentative if they didn't.

Then there's the prisoner on community service who is trying to avoid work, the drug addict on 'maintained addiction' or the alcoholic who has no intention of stopping drinking. None of these patients is acutely ill. They don't want work, but neither do they want to be hospitalised or to engage with social services.

The best treatment for mild depression, personality disorder or other borderline conditions is to go back to work, keep up regular activity, be part of a team. Low mood is not depression and people arguing for sick notes are unlikely to kill themselves. It's the patients we never see, or those who attend for an unexplained benign condition as a call for help, who may be at risk.

Daily battle

When I started working in a surgery in Fulham 10 years ago, I worked out that 9% of my daily consultations were for unjustified sick notes, which meant a daily battle with patients. Doctors get the patients they deserve, and this is why I stuck to my guns. No sick notes for the lazy.

After a few weeks, the troublemakers were avoiding me, except when they had a real medical problem. They didn't like me, but they respected me. I never expected to see three of the most abusive and aggressive patients again, but within weeks or months they all came back with genuine problems and were nice and quiet. One even wrote in a surprising letter that I was the best doctor he had ever seen (which is of course excessive).

So how has the UK system gone so badly wrong? An important feature of British society is the notion of trust. This beautiful quality of honesty, politeness and trust once defined very well the traditional image of the British gentleman. As a result, British doctors are taught to believe what people say. It is not considered right to doubt the words of a patient, even if that leaves the medical system open to abuse.

Some GPs grant sick notes simply to avoid conflict, but others do so to preserve the doctor-patient relationship, and may even give a sick note at an early stage to gain the patient's confidence. But what is this relationship if the patient is cheating or manipulating the doctor? The relationship is already gone. Trust is based on competence, not on smiles. Paradoxically, it is by making a patient angry at being refused an unjustified sick note that you lay the foundation of a good relationship.

In France, GPs are not obliged to see patients they don't want to, so patients learn to behave themselves. In England you can self-certificate for up to one week - in France a single day requires a certificate. Inspectors track down cheating patients, and they are fined if seen working while signed off. A patient's word - for instance, their description of back pain - is not enough to be off work if an MRI scan is within the norms. And patients have to pay their GPs, even if they don't get a sick note, so they think twice before trying to get one.

GPs in France receive yearly statistics of their performance on sick notes and if they hand over more than expected and can't justify it, they can be in trouble. There is also a cultural difference: it is easier to say no in France than in England.

How many times have I heard from GPs in the UK that it is not worth confronting the minority of patients who abuse the sick notes system? 'We are not gatekeepers to the benefits system,' as the BMA says. But as a consequence, the cases have multiplied. 'Stress' is now costing an amazing 13.5 million working days a year in the UK, more than during the crippling strikes of the 1970s. If we don't deal with patients directly, who will? We are the gatekeepers, we are the front line of the NHS, for anything from referrals to sick notes.

Expensive waste

The Government's answer to the problems of the sick-note system is to promote 'fit notes' instead, or notes detailing what the patient can do rather than what they can't do. Another absurdity. If patients want to work they will already have found some agreement with their employer. If they are intent on not working, they will tell their GP they can't do what the GP is suggesting they can.

The guidance tells GPs to write to the employer detailing what the patient can do, and the employer is supposed to choose an 'independent' person to assess those suggestions. It is supposed to reduce the pressure on us, but will actually lead to more pressure from patients, and more manipulation from them, to ensure they are not made to go back to work. The result? Another expensive waste.

Neither is tick-box medicine the answer. One of my patients was diagnosed with severe depression by a colleague who found him to be at 23/30 on the scale. I saw him the day before and found only 7/30, calculating the result in a synthesis after the consultation. I had difficulty explaining to the nurse that there was nothing significantly wrong with him. The next day she told me: 'You were right! I saw him laughing with friends in the city centre.' Patients simply know what to answer to be considered depressed without taking the risk of being sectioned, and we help them even more with these boxes.

The evolution of the sick note system is certain to make the life of the GP more complicated. We shouldn't abandon the power to decide by ourselves whether a patient should receive a sick note or not. Have the courage to say no and you will avoid the troublemakers and heartsinks. Your quality of life and work will improve - unless, that is, you like to deal with them.

Dr Alexandre Fuzeau is a sessional GP in London and director of locum agency Normand Consultants Ltd

Just say no to sick note requests

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