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Study on sickness certification and return to work

research-transStudy on sickness certification and return to work for chronic pain patients in general practice; report on findings for participants.

Thank you for participating in the above study. The study aims were to consider:

  • How GPs and chronic pain patients negotiate sickness certification with particular reference to the new fit note
  • Barriers to work as perceived by both GPs and patients
  • How return to work may be facilitated, when appropriate

The researchers interviewed 14 GPs and 28 patients. Ten GPs were male, and four female, and their practices included single handed, multiple partners, rural and urban, in the South West. They were contacted via mail shots, and by one of the researchers publicising this study at GPs’ training events. Six patients were male and twenty two female, reflecting the gendered proportions of those living with chronic pain conditions.

Their diagnoses were varied, including chronic lower and upper back pain, RSI, fibromyalgia, pelvic pain, abdominal pain, rare conditions such as Forestier’s disease, and Ehlers-Danlos Type 3 Hypermobility, and chronic pain with no diagnosis. Fourteen patients worked (mostly full time) and fourteen did not work (some of whom were retired on ill-health grounds), although all had worked prior to becoming unwell. Patients were contacted via posters in GPs’ waiting rooms, and via an internet advert placed on charities’ websites. From the study interviews core themes emerged:


Study highlights

The role of the chronic pain patient and of the GP.

  • Patients felt that “there is no box for me”. Some patients had no pathology that can currently be observed by medical technology, hence felt as if they are treated as malingerers by GPs, employers and family. These patients felt strongly that matters would be different if they had “evidence” of their condition, or visible signs of it. Other patients felt supported by GPs, employers and family, whether or not they had observable evidence of their condition.
  • GPs felt that their role is to support the patient, whether or not a diagnosis had been reached, although many patients found this difficult as they wanted a diagnosis in order to help explain and manage their condition. Some GPs commented on the intellectual discomfort that chronic pain conditions can bring, whereas others felt that chronic pain patients were interesting patients to treat, in part because of the uncertainty that may surround them. Some GPs felt that chronic pain patients are difficult to manage because they appear to resist change, although there was understanding of the suffering that chronic pain conditions cause.
  • Both GPs and patients felt under-supported by the state, in that pain management programmes take a long time to access, are not suitable for everyone and require more top-up than is available. Nearly all GPs and patients felt that employment services do not understand the needs of chronic pain patients, hence have not been helpful. However, there were a few localised exceptions to this rule, which were based on appreciation of individuals’ efforts rather than upon what (re)employment and job rehabilitation systems can offer per se.

Sickness certification was seen as a problematic area by GPs but not by the majority of patients.

  • Patients felt that if they needed a sick note, they would get one, and only a few of patients felt they had been pressurised into taking a sick note when they did not want it (and most of those were subsequently grateful for this intervention, as they later considered that their GPs’ advice to stay off work was right).
  • Nearly all GPs reported being asked for sick notes by patients when they did not think it best for the patient’s health to give them. Twelve out of the fourteen GPs said they would never refuse a sick note, even if they thought it would not help their patients, to avoid damaging or even ruining GP-patient relationships.

  • GPs used techniques to minimise effects of sick notes e.g. issuing them for shorter and shorter periods each time, actively engaging the patient in target setting, and contacting employers by letter to try to get targeted support for patients (which almost without exception got no response). Some GPs felt that Occupational Health (OH) specialists would be better patient assessors and that it is very difficult to make sensible decisions about work within short consultations, although this was ameliorated if the patient was well-known to them.

logo_centrefor_painResearchBathGovernment materials and rhetoric that work is good for us

  • Every interviewee agreed with the principle that work is good for most of us, most of the time, but there were many provisos, which people felt very strongly that the Government is not considering. These included work that is badly paid, of low status, with poor terms and conditions, and where work is perceived to be a causative factor in the patient’s ill health. Both GPs and patients commented that patients are caught in very stressful working environments, often to do with working relationships breaking down, and also as recession survivors have more and more work to do within the same roles. These factors made GPs feel that time off work may be helpful for patients. However, all GPs were aware that after a period of time off, it is very difficult to return, and were keen to avoid that happening to their patients.
  • The patients who were working displayed extremely strong work ethics, in the face of challenging barriers to work. Such barriers included the unpredictability of chronic pain conditions, managing travel to work, having to cover up reasons for ill-health and for why and how it affected work, and conversely explaining chronic pain conditions to co-workers. Some patients stated that their workplace could not have been more supportive; others felt stigmatised, unsupported and even that they had been driven out because of their chronic pain condition.
  • The patients who were not working agreed that in principle work is a positive thing, but felt it was simply an impossible goal for them to attain at present, or that they had been forced to leave jobs which had damaged their confidence, although some were happy to have been retired on ill-health grounds. Many patients felt angry, as they felt that they are viewed as malingerers by society. Some were frightened about the Government’s re-testing of benefit recipients.

Views on the new fit note

  • GPs had mixed views about the new fit note. Some felt it prompts more nuanced thought and comments, encourages a better duty of care from employers, and focuses the consultation on capacity not incapacity. However, some GPs had used the old sick note comments box to discuss phased return to work, amended duties etc anyway and saw no added value in the fit note. GPs wanted e-training on the fit note/work and health, and there were criticisms of the design e.g., two date boxes and some wording was seen as confusing.
  • Some patients saw the fit note as a way of trying to force them back to work before they felt ready. Others said the note had communicated helpful messages to their employers, and felt that it was useful to have information alongside that from other sources, such as OH departments. There was a perception amongst patients that employers will act upon GPs’ advice, although most GPs had not experienced this.

Study participants’ suggestions for change

  • Patients made a number of suggestions for changes. They recognise that GPs are generalists but felt they should have a clearer understanding of the impact of chronic pain conditions on one’s life. Patients also reported wanting more understanding and awareness of the effects of living with chronic pain, from GPs and also from society in general, although many commented that it is very difficult it is to communicate how pain limits one’s life to someone who has not experienced this.

  • GPs also recommended some changes. They understand one does not have to be 100% fit to work but felt that employers need more education and support about this. GPs felt many employers did not respond to sickness certification with any care, although there was recognition that it is hard for small companies to absorb amended duties, phased returns etc.

  • GPs and patients thought that employers, particularly line managers, should have better training on chronic illnesses and also on all relevant legislation, as well as on how they can access support so that they can, in turn, provide better support to employees. Both groups felt that resources such as disability employment advisers are not well known about or utilised, and also that the quality of such support services must be raised and standardised. They also wanted faster access to secondary and tertiary level pain management care.

Main conclusions from this study

Simply giving GPs and patients information and training on work, health and wellbeing (including fit notes) will not change sickness certification negotiations. Information alone does not account for GP-patient relationships, the many provisos that GPs and patients judge are important in considering if someone should work, struggles for identity as a legitimate patient or worker and whether people can access appropriate support from (re)employment services.

Future directions

We hope to publish a fuller account of the methodology and findings in an academic journal and both this report and any fuller publication will be sent to DWP contacts. As a follow-up study, the research team is negotiating access to some employers, to interview Human Resources and OH workers, line managers and employees.

This was felt to be important as both GPs and patients discussed employers frequently. Please email any comments (and employer contacts, if you have them) to This email address is being protected from spambots. You need JavaScript enabled to view it.. Thank you for your participation; we are extremely grateful to you for giving up your time and sharing your valuable experiences.

Oct 2010

Principal Investigator:     Professor Christopher Eccleston, Director of the Bath Centre for Pain Research

Chief Investigator:           Ms Elaine Heaver, Bath Centre for Pain Research

Research Team:            Dr Edmund Keogh, Senior Lecturer, Department of Psychology; Dr David Wainwright, Senior Lecturer, Department for Health

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