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All this not working is not working

All this not working is not working

Columnist Dr Katie Musgrave questions whether signing twenty-somethings off work will really help them in the long run

Another day, another request for sick notes. This time it has been a handful of twenty-somethings. They’ve been signed off for months, haven’t engaged with social prescribers, and all have a diagnosis of depression or anxiety. They live with their parents and don’t feel able to go to work. I say ‘they’ because I’m signing off the third of the day. Not only is this sad, but it is also worrying for our society.

I don’t know about you, but I struggle nowadays to make time to explore my patients’ willingness (or not) to go to work. I remember in the past, as a fresh-faced trainee, discussing barriers to work and trying to encourage patients to look for jobs that they could manage. But in the midst of mounting pressure, it seems these conversations about work have been deprioritised. Have we given up the battle? Are we now all just signing everyone off, no questions asked?

The sickness absence rate in the UK (the percentage of working hours lost because of sickness or injury) increased to 2.6% in 2022, up 0.4 percentage points from 2021, and 0.7 percentage points from the 2019 pre-pandemic level. It is now at its highest point since 2004, when it was 2.7%.

Looking at the chart over recent decades, there has been a steady decline almost year on year from when the records began in 1995. Something happened in 2020 that has sent the rate soaring. Was it sending everyone home for several months and giving out lots of money in furlough? Was it the stress of isolation, loss of social connections, the mental health impacts of the pandemic and lockdowns, as well as government / public health messaging around this time?

Is it sky-high rates of long Covid, and permanent disability in the population as a result of the virus? Is a more insidious societal malaise and ennui filtering through – resulting from our addiction and enslavement to modern technology, particularly marked in the young? Or might it simply be that GPs are too overworked and overwhelmed to engage with patients about their employment, and now simply sign off anyone who asks for a sick note?

‘Who cares?’, you might be thinking, ‘I’m not paid to police people’s work, and I haven’t got the time or inclination to enter into a debate about it with my patients.’ But when 20-year-old after 20-year-old presents with a request to be signed off for months on end, with no physical disability and a diagnosis of anxiety, you have to start to question who we are helping.

By signing off yet another 20-something, am I not helping to consign them to a destiny of worklessness, increased anxiety, reduced activity, dependence on benefits, and ultimately a shorter life expectancy? The more young and physically healthy people that we sign off as being unfit for work, the lower the productivity rate of the UK, and ultimately the poorer the public services available to help them lead healthy lives. There is, of course, a big difference between signing off a 68-year-old with arthritis, and a fit twenty-year-old; with hugely different lifetime and societal impacts.

It doesn’t make sense to me that GPs should be the arbiters of whether patients are fit to work. First, we are too busy dealing with medical problems (has anyone noticed the crisis in our numbers?). Second, there is no incentive whatsoever for us to enter into a debate with a patient about this – we offend them, they complain about us, and the patient-doctor relationship is eroded. And third, we are all just too soft to push the issue anyway. It’s far better to have an independent system where a print-out of recent consultations can be taken to a workforce assessment, and someone else can determine what kind of work might be possible.

Still, on current trends, in another few decades there may be no one left in the workforce. If that includes GPs, then we won’t be able to dole out any more sick notes.

Dr Katie Musgrave is a GP in Devon and quality improvement fellow for the South West



Please note, only GPs are permitted to add comments to articles

Dylan Summers 30 May, 2023 12:12 pm

“Looking at the chart over recent decades, there has been a steady decline almost year on year from when the records began in 1995”

Clarification needed:

The previous sentences refer to the “sickness absence rate”.

So does a “decline” in the sickness absence rate mean declining absence numbers (yay! more people in work!) or a deteriorating situation (boo! fewer people in work!)?

Nicholas Sharvill 30 May, 2023 1:29 pm

Important topic made more difficult with the new range of lables from hypermobiity , fibromyalgia and the various learning differences be it ADHD ASD borderline personality disorder etc BUT the evidence is that for all these as well as for back pain work actually is part of the treatment in the sense that it improves prognosis (the benefit to the economy’s for others to sort)
So yes it takes time but our professional role is to share information this but issue fit notes with criteria not sick notes and dont re issue without F2F. Many will disagree and even more annoying is when other issue sick notes without any ”plan” then others have to pickup the pieces.

Dr No 30 May, 2023 1:36 pm

I share your concerns. I think what has changed is that worry is now anxiety, feeling sad is now depression. It’s a change in the language use which has medicalised upset into “mental health”. So now these unfortunates have a medical problem rather than a personal/social one, which of course entitles them to a sick note. Blame sloppy use of language by the media. Actually read a very interesting piece in the paper the other day about how patients with “proper” MH diagnoses were being squeezed out of the system by the morass of youngsters with varying degrees of stress and upset masquerading as Mental Illness.

SUBHASH BHATT 30 May, 2023 2:09 pm

It is frustrating indeed. I share same view. Anxiety and depression has no beginnings or end.. I tell them to try and find work maximum of 16 hours and they would not loose benefits. It may or may not work for all. Working help improve depression..

Andrew Jackson 30 May, 2023 2:24 pm

Long term sick is difficult to change despite us knowing it is good for patients to work.
We often underuse the comments box and this can be used to start to try and mould the agenda into a more positive outcome eg. try putting ‘recommend meeting to discuss sustainable part-time working’ or something like that to try and brake the status quo.
It can start to change the patient’s mindset and also get the DSS into a work related mode.

David Church 30 May, 2023 2:31 pm

There was a lot of chronic sickness absence in 1995. Much of this was caused by Jobcentre staff seeking to avoid finding work for unemployed people, by screening them for the slightest sign of anything they could send them to the GP for a note for.
Of course, from 2020, there was a lot of deliberately introduced chronic sickness and acute infections, in the form of the Covid the government recklessly allowed in to wreck our economy – indeed, I am somewhat surprised that absence rate have not risen much more, seeing as the current acute covid rate is approximately 3% all the time……..
and the chronic long-covid rate of disability is about 4% of the working population, I think?
(and continuing to grow!)

Michael Green 30 May, 2023 4:16 pm

No one is allowed to feel anxious or sad. Nor indeed awkward or shy or even eccentric or a bit weird.

Dave Haddock 30 May, 2023 7:52 pm

Reward the sick role.
Pay people for being “ill”.
Wonder why sickness rates rise.

Mark Howson 2 June, 2023 7:24 am

We are not in a position to determine ability to work we are not trained in OH assessments and have not seen them at work or at home. So my solution is to give sick note with statement that I am not OH trained then after 3 months I mark it for “indefinite” time and say “GPs do not do OH assessment for fit notes and the employer or DWP can consider an assessment But there is no need for further fit notes until an assessment has been done.” Then if employer or seeks further fit note despite this and with no assessment I write the same with “maybe fit for work”. This allows the person to seek OH help and prevents breakdown by refusing a fit note.

Rogue 1 2 June, 2023 2:41 pm

I support the role down under, they dont issue sick notes!
If you are off sick, you go on reduced pay
Its upto a discussion between you and your boss as to how to get you back earning

Anonymous 2 June, 2023 8:14 pm

Keep signing them off. Keep fuelling their sense of entitlement. Amazon prime society. Maybe they will bump into you somewhere on holidays in Ibiza or Tenerife.
Or you might say no. Ask them to come and explain their issues to your face. And then challenge it.
The same way you are challenging medication noncompliance or codeine abuse.