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Should it be a GP's job to issue well notes?

The well note would streamline sickness certification and make life easier for GPs, patients and employers, argues Professor Sayeed Khan. But Dr John Canning disagrees, arguing that expecting GPs to assess eligibility for work would compromise their core role in making patients better and might put confidentiality at risk.

The well note would streamline sickness certification and make life easier for GPs, patients and employers, argues Professor Sayeed Khan. But Dr John Canning disagrees, arguing that expecting GPs to assess eligibility for work would compromise their core role in making patients better and might put confidentiality at risk.

Yes

The sick note is on its last legs. We know GPs don't like sickness certification and employers certainly aren't happy with the current system, so it's high time we looked at ways of improving it.

One solution might be to get rid of the Med3 form and let the Government find another way to deal with statutory sick pay.

Even then, though, patients would still come to their GPs to discuss occupational issues and employers would still want a piece of paper about an employee's fitness for work.

Another suggestion could be to get another group of professionals, like specialist occupational physicians, to do it. But even if they were willing to take over the role, there are fewer than 600 in the UK1, so it's unlikely they would be able to.

So we need to look at other ways of improving the sick note, and this is where the proposal for the well note comes in. There's quite a lot in it for the GP.

If a well note had tick boxes for simple functional statements like ‘capable of sedentary, non-manual or part-time work', it would make it easier when considering what the patient could do.

It also puts the onus on the employer to find the patient suitable work.

And most employers with more than 500 employees have some form of occupational health service2. A GP may then decide to tick a box – ‘needs an occupational health assessment' – give a sick note for a week or two and ask the patient to visit the occupational health service.

The well note is not designed to deal with the patient from hell who marches into the surgery and demands a sick note. It is about the large group of patients who listen to the advice and information GPs give them.

Unique position

GPs are in a unique position to provide patients with evidence-based advice about work.

A comprehensive evidence review Is work good for your health and well-being? was published in 20063, which revealed long-term sickness absence or unemployment is bad for health. It increases by two or three times the risk of poor general health, with a 20% excess risk of mortality.

Conversely, the evidence shows that work, for the majority of people, is good for wellbeing and that getting back into work can be therapeutic. A well note, therefore, is psychologically much more constructive than a sick note.

It is easy for GPs to be cynical about employers and their motives, but the majority want to do the best they can for their employees.

This is not altruism – it makes good financial sense to reduce unnecessary absence.

Many employers would much rather have an employee return in a restricted role than be off entirely. GPs may also be pleasantly surprised by the number of employers willing to pay for private appointments to circumvent long NHS waiting lists.

All employers want is the chance to be more active and use the reformed sick note as a means of communication.

Nor should GPs be intimidated by the implications of this change. There are already learning modules for GPs on the web4 and the RCGP has developed a National Education Programme, which has been piloted in workshops around the country5.

These modules have been independently evaluated and the feedback was very good. GPs became more confident in agenda setting and negotiating strategies with patients to aid early intervention. They were able to incorporate these elements into a seven-minute consultation.

Everyone could benefit from a well note. The proposal is being assessed by GP representatives and other stakeholders and will need to be trialled. But I believe that the time is right to give it a go.

Professor Sayeed Khan is a former GP, fellow of the Faculty of Occupational Medicine and member of the Health and Safety Commission


No

GPs are not, and will not become, the police of the benefits system. Our duty is to work for the benefit of our patients.

Work is, despite what it feels like at the end of a long day, good for us. Successive governments have striven to curtail the number of people on benefits related to ill-health. This has often been an unsuccessful battle, with claimants being shifted around the system, frequently without real benefit to them.

One thing has been consistent: it is always GPs' fault for signing too many people on the sick. And so we have the latest idea, for us all to issue well notes.

This concept can only have been dreamt up by people who spend their time advising on how to run general practice rather than actually doing it. Asking GPs, who spend hours each week issuing sick notes, would have been far too obvious, and would not have given the desired answer.

As GPs we are trained as specialist generalists to work with our patients to help them achieve the best possible outcome for their symptoms or disease.

We have a duty to discuss with them the relationship between their work and their illness, and we can suggest the benefits of work, but we have no influence over the main protagonists in the battle for the Government to get people back to work – employers and the Department of Work and Pensions.

The key to getting people back to work early is a sympathetic employer who is able to assess the situation and act appropriately.

I am fed up of asking patients to talk to management about getting back to work as they recover, only to be told the employer ‘isn't interested'.

Just occasionally an enlightened employer appears and the patient is able to ease back into work. But a well note, advising what an employee can do, will be of little use if employers continue to be deaf.

Convenient targets

So why are employers behaving in this way? It seems to me to be a combination of cost containment, a fear of risk, but above all because GPs are a convenient target for blame.

For the Government and its friends in the CBI to complain that it is GPs' fault that people are off work for too long beggars belief.

Only 12% of UK employees have access to a trained occupational health doctor. A few more, but still fewer than one in five, have access to a comprehensive occupational health service and just over 40% can access some basic services. For small companies these figures are a gross exaggeration of reality.

Employers, both public and private, must get their house in order before the Government even considers telling GPs what to do.

Only when the CBI can say effective occupational health services are universally available can it express views on certification.

Only an occupational health service can assess an employee, matching them to work available, advising on management and assessing risks.

GPs are not trained to do this, nor should they be; our role is different, helping the patient return to good health. This may include advice about returning to work, but it is done in the context of a partnership of care, not as a way to manage absence.

Fundamental to the relationship between a patient and a GP is our duty of care and confidentiality.

GPs have no relationship with an employer and must not breach a patient's confidentiality in a sick or a well note – which may be seen by all and sundry.

Occupational health doctors and nurses have a different relationship with employers, which does not place them in conflict with their core role.

Dr John Canning is a GPC member and a GP in Middlesbrough

Sayeed Khan

Neither GPs not employers are happy with the current system

John Canning

GP are not trained to do occupational health, nor should they be

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