The data confirmed previous work in this field that described the struggle that GPs experience with sickness certification, most notably the threat to their advocacy role. Emergent theory from this study is that these tensions appeared to be magnified when dealing with depressed patients and exacerbated by their difficulty in determining whether work is a help or a hindrance and the positive (and negative) effects of work as well as the positive (and negative) effects of time away from work. It was clear that GPs found it difficult to predict how individual patients might cope with work while experiencing symptoms of depression and that multiple factors, many of them non-clinical, must be considered when deciding on the most beneficial course of action for patients. Sickness certificates therefore represented a powerful intervention for GPs, and as an intervention they also carried potential side effects.
Individual interviews were conducted with 30 (20 men and 10 women) general practitioners across Scotland [See Table ]. Eight of the interviews were conducted on the telephone and the remainder were face-to-face, and lasted approximately one hour. Although we purposively sampled practices where there were differences in proportion of incapacity benefit claimants, we found that this did not impact on GP views or self reported behaviour in relation to decisions around sickness certification and depression.
Summary of practice details of gps interviewed
Advocacy and gate keeping: an inherent tension
Throughout the interviews GPs acknowledged that by virtue of their gate keeping role, everyday decisions about sickness certification have potentially far-reaching consequences that affected not only the patient but also families, employers and ultimately society. Feeling at odds with at least one, if not several, of these often competing constituencies was common. Work, though universally regarded as therapeutic in the right circumstances, could also be the source of illness and GPs had to offset the benefits with potentially harmful effects of presenteeisma.
"Forcing somebody to go back to work who isn’t healthy enough is not the right thing, it’s a bad thing, in a same way taking medication that is not the appropriate medication is a bad thing (GP27)"
The need to be mindful of the impact that symptoms of depression may have on work, to be empathic about patients’ feelings of being stigmatised, and to appreciate that patients’ difficulties may originate in the workplace was emphasised by GPs. Often these are areas where GPs feel that there is a particular need to provide additional support to their patients.
The arbitrary nature of the assessments patients undergo in order to qualify for benefits was commented on, and specifically in relation to mental health, and this reinforced the need for GPs to do what they could for patients within such a bureaucratic system
"Where do you draw the line....., someone somewhere decided 8 points or 10 points…you get incapacity or you don’t? …or mental health …a big group of people, all of them did have a degree of mental health problems - but there was a spectrum of illness and someone arbitrarily decides you get incapacity benefit or you don’t.(GP21)"
All GPs talked of the centrality of patient advocacy in their remit. In this context advocacy referred to being aligned with the patient as well as acting on instruction from the patient (as opposed to ‘advocacy’ in acute mental health settings where professionals are often seen as the antithesis of providing a voice for the patient). There was some variation in the extent to which GPs negotiated with patients about sickness certification but GPs felt bound by their advocacy role, which many conceded could give rise to internal conflict, as the following extracts demonstrate:
"GPs are patients’ advocates and something comes in front of you and you have got a 50 / 50 choice whether you give a sick line or not. As an advocate they [the GP] can do as they want because you are not their employer, and I’m sure there are some times I’m doing the right thing for the patient but not the right thing for the workforce or society, or possibly the patient. But they [patients] want it [sick line] and despite discussion they’ll get it, and having that place in society where the doctor moniker, using that status to decide whether someone is fit for work or not is not always a medical decision and is sometimes quite clear, if someone breaks a leg give them an 8week line
[certificate], that’s not a problem, you know ….
The role of ‘gatekeeper’ within the sickness certification system is a less ambiguous task in the presence of physical ill health than it is for mental health problems. In the following extract the GP raises the tension between patient advocacy, the therapeutic nature of work and how this might threaten the GP patient relationship
"Obviously, one, as a GP is constrained by this advocacy role that they are the patients advocate as well so that… but certainly I’ve spend many, many hours arguing with people that really the best idea for them is to continue in work or whatever rather than for them to, because it will only enhance their sense of depression if they then flunk out of a job if they are holding a job or whatever but obviously there have been people who have stomped out of here and left our surgery for good because I’ve refused to give them a line. (GP18)"
Often patients are dealing with an array of complex and associated problems. Patients’ home lives may be worrisome; they may have caring responsibilities or have relationship difficulties with partners and/or children. It is this elaborate and individual picture that led GPs to report that patients respond to, and cope with, symptoms in different ways and the impact, therefore, of depression on work is frequently unpredictable:
"There are so many factors in even a straight forward thing that to take even something like depression is just, it’s just impossible because some people will work through it and some people will take two weeks off or three weeks off and take anti-depressants and they will kick in and it will function fine and some people will never ever work again but you can’t, it’s really hard to pick them out. (GP 11)"
For GPs this complexity is at odds within a sickness certification system that demands a more simple judgement.
The therapeutic potential of time off work
Many GPs felt reluctant to describe a typical pattern of sickness absence for patients but as the following extracts demonstrate GPs were unequivocal about some presentations:
"well there is a group of people who have got major mental health problems who are just unemployable due to that and waken up in the morning and getting through that day is enough of a challenge, it just the concept of having to go to work just isn’t an option and the majority of them, there is obviously a small percentage of them who’ve got psychosis or schizophrenia but the majority have got major personality disorders, severe anxiety, severe agoraphobia, mainly due to their upbringing where they were beaten up, abused, parents where alcoholics or whatever, they have got self esteem issues and they just haven’t got the capacity to develop normal relationships with people in the work place. There is a huge group of them who I would suggest are unemployable and they are not resistant they are just unemployable. (GP14)"
"People with true and straightforward depression are straightforward and work sometimes, gap time from work is sometimes worthwhile mainly because their concentration and their poor state in other things is actually making it difficult for them to function. I think if you have a straightforward depression it is usually quite obvious that a short gap and I that’s what patients feel as well but I think the big problem with depression is the complex things that people often have as associated problems you know.(GP15)"
GPs reported that most do take some time off work and return fairly quickly. GPs were characteristically supportive of patients having a short time away from work to provide some much needed ‘breathing space’. Indeed most GPs thought it necessary to provide some short respite early on in the patients’ illness:
"“Work is something that you can actually put into a lay-by for a fortnight or a month until you get going on medication and start to feel a wee bit more confident that you can and are able to manage. It’s quite a reasonable thing, I think time away often helps people to stay in jobs, take time off for a wee while and get them back quickly.” (GP2)"
GPs generally thought it reasonable for patients to take some time off, and this was often attributed to the latency before antidepressant medicines became effective. Implicit in the discussions was that for the majority of patients this approach was helpful in reducing the overall burden of sickness:
"Generally they get back to where they were, the problem is dealt with. They are on an antidepressant, they go for counselling or both and eventually go back to work. If they are off work, they are off for a couple of weeks, a month or six weeks but they go back to work, they don’t stay off. I could think of less than a handful that are off for prolonged period (GP21)"
GPs perceived an increasing trend towards patients presenting with ‘work-related’ stress. Such difficulties ranged from bullying and harassment to simply being unable to cope with increased demands and pressure at work. Where patients’ problems stemmed from a problem at work, some GPs felt that sickness certification served an important function: they offer a catalyst for patients to discuss challenging aspects of their work with employers or superiors. In the following extract one GP describes how he explains this:
"I say “How do you want me to write this? This can cause problems, or may cause an issue which might be good, might be bad. It might be good because it will highlight to senior management or the personnel department that your immediate boss is causing problems.” I offer it to them and say this may have implications. Some say no and some say “Yes brilliant, I want it to come to light’ (GP14)"
The type of work was important. Certain types of employment may be more prone to absence, particularly in low paid and un-skilled sectors:
"We have a large employer here, I can’t give you the name, which is a call centre and clearly it is a very difficult place to work, it is a boring frustrating job with lots of sickness and a lot of long term sickness and, we’ve seen in the last few months … they have obviously had to address this issue at their company and they brought in some external divisional health experts who are doing things like full medicals, motivational interviewing, financial rewards, offering flexible return packages and it seems to be working very well. (GP 25)"
Experiencing mental health problems also impacts on patient help seeking behaviour. With depression, patients may have been experiencing symptoms for some time but attempted to maintain normality, and ‘hold work together’. GPs described how patient recognition of their loss of ability to cope with work, or ‘struggling at work’, often provides the trigger for help-seeking:
"One of the reasons is, because they are not actually coping at work and that is ….very distressing and [they say] “Well that’s the reason why I came” and maybe things have been going on at home for ages but when it’s finally affecting their work then they decide that you know they need to come …(GP16)"
GPs also talked about patients being reluctant to take time off work because they do not want to burden colleagues’ workloads, Yet, patients may reach a tipping-point where it becomes more difficult to sustain work and fairly quickly work becomes an additional pressure. In such situations GPs rationalised that impaired cognitive function may lead to impaired performance at work, which in turn exacerbates feelings of worthlessness and guilt, both common symptoms of depression. There was therefore, a therapeutic imperative to recommending time off work.
The therapeutic potential of work
"Chronic depression often precludes people from getting back into gainful employment, which is unfortunate because the work environment in its own right can be one thing that is likely to stimulate people into normality”. (GP8)"
GPs were certain about the advantages of work, a position reiterated in all interviews. Indeed, the structure, routine and purpose that employment gives patients was thought especially relevant for those with depression. Work could provide an escape from problems at home and generally promote self-confidence and well being:
"I don’t think it needs a reminder because I have seen what work can do for people in both ways, good and bad. If I feel that the patient will benefit from getting an occupation and more or less getting a normal life, something regular, something to get up for in the morning, then I would be the first person to encourage that. (GP1)"
However, as the GP above states, work can be both ‘good and bad’. What emerged from the GP interviews was that notwithstanding the benefits of work, remaining in work could be detrimental for some patients. A number of factors must be taken into consideration when judging what is best for individual patients. These include the type of job, the patient’s home situation, relationship with employers, provision for occupational health input from employers.
Sickness certificates: a powerful intervention
Dealing with the sickness certification system and depression may pose several challenges for GPs, including the testing of their advocacy role and achieving the appropriate balance between the positive and negative impact of work on a depressed patient’s illness. What emerged from the interviews was that the sickness certificate is regarded as a powerful intervention, and one which is important in the portfolio of tools available to them. One GP reflects that this is not always sufficiently recognised by colleagues
"I think it should be the case that a sick line is a generally well considered thoughtful bit of medical intervention and I don’t think it is at the moment. It is a very useful bit of therapy, it can be enormously helpful to people to know that their doctor is of the view that they are unable to work. It can be an enormous relief for some people and can be part of the therapy of their condition, it’s a powerful tool. It’s as powerful I think as prescribing. (GP25)"
The symbolic importance of the sickness certificate in the doctor patient relationship for this GP is clear. Yet such a powerful intervention might also have adverse effects. GPs stressed the need for the careful thought when sanctioning time away from work because there were also potentially counter-therapeutic, and even side effects associated with sickness certificates.
"Often a patient with depression will also have anxiety ....sometimes there is the option of prescribing a short-term benzodiazepine. I don’t mind doing that occasionally but the side-effects are dreadful. And I believe that a MED 3 [sickness certificate] is the same as for the [drug] category, that it really is a very powerful intervention which produces a very quick turn-around and makes the patient feel better, quickly, takes the pressure off them. But then the downside is that they could, as with benzodiazepines, in the same way that they become very addicted to them very easily. So my thinking is really along those lines, that a person can become addicted to sick-lines. (GP26)."
It is for these reasons that GPs use of sickness certification, and long term sickness certification, is a carefully considered process for individual patients, taking account of their lives, whether their ability to cope at work is compromised, the types of work they do and how this affects their well-being, and the potential risks and benefits of individual and multiple sickness certificates.