#fit note

Introduction

The relationship between the state, the doctor and the patient has long been fraught with tensions and contradictions. The doctor’s legitimacy and right to practise depend ultimately on sanction and registration by the state (Doyal, 1979). Ethically, doctors are obliged to pursue their patients’ best interests, but they must also act as gate-keeper to services, benefits and exemptions from work (Hussey et al., 2004). These imperatives are not necessarily incompatible, but, particularly where the funding of health services is governed by the state, the question arises as to whether the doctor’s primary purpose is to serve the patients’ interests or contain costs. This apparent contradiction has intensified in the United Kingdom where recent policy initiatives have sought to significantly reduce the number of people claiming incapacity social security benefits by returning them to work and reducing rates of sickness certification.

Medically certifying permission for temporary absence from work, known colloquially in the United Kingdom as ‘sick-listing’, is a daily occurrence, and a common source of challenge and contention (Wynne-Jones et al., 2010b). Sick-listing can provide necessary periods of recuperation and state-sanctioned legitimation of entry to the sick role (Parsons, 1951), including uptake of wage replacement and other benefits where such collective systems exist. Yet sick leave can also increase disability, extending the sick role unnecessarily (Waddell and Burton, 2004), resulting in poor health outcomes for patients, and considerable expense for tax-payers and employers (Black, 2008). Sick- listing rates have risen greatly in the United Kingdom since 1970, particularly for mental health problems and musculoskeletal disorders ( -Jones et al., 2010a). Sickness certification is positioned as a socioeconomic policy issue as well as something that should be changed for the benefit of patients’ health (Black and Frost, 2011). The UK government responded to rising rates with several policy interventions, most notably changing from sick to ‘fit notes’ in April 2010, replaced by an electronic version in 2013 (Department for Work and Pensions (DWP), 2013a) and creating a national education programme for primary health physicians (called General Practitioners or GPs in the United Kingdom), patients, Occupational Health (OH) professionals, employers and employees.

The first intervention is formally known as ‘the statement of fitness for work’, and colloquially as the ‘fit note’, because it focuses on capacity rather than incapacity. GPs can still classify a patient as not fit for work, but the alternative category of ‘fit for work’ has been reworded to state that the patient ‘may be fit for work taking account of the fol- lowing advice’. Four options follow: a phased return to work, amended duties, altered hours and workplace adaptations.

The second intervention is a national education programme comprising online and paper resources for stakeholders, summarising evidence that ‘safe and accommodating’ work is good for the health and well-being of most people, and that employees do not have to be 100% fit to return to work (Waddell and Burton, 2006: ix). Evidence suggests that early return-to-work interventions are not associated with any increased risk of more sickness absence or risk of recurrence (Staal et al., 2005; McCluskey et al., 2006). Waddell and Burton’s review concedes that a minority of people may experience con- trary health effects and be better off not working, depending on the nature and quality of particular jobs, and recognises the need to consider social contexts. Black and Frost (2011) concur. Even these strong proponents of the health benefits of work acknowledge that work can sometimes be a cause of poor health. While the evidence suggests that most patients are better off at work, these caveats make it difficult to know with certainty whether a particular patient would be better off at work. Government policy initiatives to reduce sick-listing diminish these caveats and appear to be largely based on a knowledge-deficit model. They suggest that if GPs and patients were given more infor- mation about the health benefits of work, then sick-listing rates would reduce, as more patients would want to remain in work and GPs would find it easier to persuade reluctant people to return (DWP, 2012). The original DWP (2012) fit note guidelines focused on correct form completion, rather than providing advice on the negotiation and communication skills which doctors need for sickness-certification consultations (DWP, 2012; Gabbay, 2010).

The above policies are based on a knowledge-deficit model that can be characterised as ‘naive rationalist’ (Russell et al., 2008), although more recently the importance of GP negotiation skills has begun to be recognised. Thus, government guidance has been revised, outlining how fit notes can guide discussion about challenging patients’ perceptions of workability (DWP, 2013b). Additionally, the Royal College of General Practitioners (RGCP) (2012) runs the ‘HealthyworkingUK’ web site for GPs, which includes e-learning modules on making difficult decisions about workability and also on patient–practitioner communication, recognising these can be challenging issues for GPs. However, the policies do not consider how macro structures affect micro-interactions in the consultation. Doyal’s (1979) discussion of the ‘political economy of health’ is a useful way of conceptualising how the positions of ‘doctor’ and ‘employee’ within prevailing structural hierarchies of power and institutional arrangements tend to influence interaction at the micro-level. Doctors occupy a contradictory location in the social relations of health, in which they must simultaneously act in the patient’s ‘best interests’ but also act in the interests of the state, for example in validating sickness claims and being the gate-keeper to benefits and other resources including sick leave. The patient/employee is also positioned in a contradictory/antagonistic relationship with the employer. Employers have an interest in maintaining or restoring the health of their employees in order to maximise their productivity; however, the same imperative may constrain the scope for workplace adaptations or phased return to work, where such measures threaten the intensification of work or diminish performance. When doctor and patient meet to discuss sick leave, it is never simply a matter of what is ‘best for the patient’ or ‘what the evidence base indicates’, but rather a complex process of social negotiation in which each party attempts to navigate the structural constraints and imperatives that their contradictory locations give rise to. As we shall see, the production of meaningful narratives about the nature of the patient’s work, the signs and symptoms of illness, and the path- way to recovery, are central to this discourse, but the production of these narratives is never open-ended or autonomous – it is always socially situated.

The limitations of the naïve rationalist approach are further highlighted when considering non-specific or medically unexplained symptoms of which chronic pain is a good example. Gatchel and Turk (1999) argue that chronic pain should be viewed as a complex, psycho-physiological set of behaviours; Von Korff and Miglioretti (2005) suggest that it is better characterised as a dynamic rather than static state, as its severity often fluctuates. Sickness certification for chronic pain is problematic because the uncertain nature of some chronic pain conditions means that doctors cannot always use biological reductionism to explain and treat the illness, and it can be hard for GPs to assess how pain affects a patient’s working capability without relying on the patient’s subjective account (Larsen and Jenkins, 2005). Chronic pain challenges the adequacy of mind– body dualism and blurs the distinction between subject and object. This indeterminacy is common to other medically unexplained symptoms which form a core part of general practice (Salmon et al., 2007), suggesting that chronic pain is a good example of how uncertainty renders the capability decision challenging (Hussey et al., 2004). As we shall see, the narrative of Evidence-Based Medicine tends to prioritise observable physical pathology over the patient’s ‘subjective’ account of the illness, but other narratives of ‘patient-centred practice’ and ‘concordance’ place a much stronger emphasis on listening to the patient, thus producing a discursive domain of conflict and contestation in addition to the structural factors described in the previous paragraph.

There is an established body of literature considering how doctors manage sickness certification, both in general (Hussey et al., 2004; Wynne-Jones et al., 2010b, 2010c) and specifically with regard to musculoskeletal disorders (Alexanderson and Norlund, 2004; Werner and Cote, 2009; Werner et al., 2012). These studies conclude that sick-listing is problematic for doctors, whose role of gate-keeper conflicts with that of patient advocate. When negotiating with patients, doctors tend to privilege the doctor–patient relationship above making a purely objective capability decision, but even so, Wynne-Jones et al. (2010b) report that conflict over sick-listing (for all conditions) is a weekly occurrence for GPs. The chronic pain patient’s experience of sick-listing is less well documented, although there are some studies, notably a systematic review of patient expectations of treatment for back pain (Verbeek et al., 2004), which reported that patients explicitly wanted sick notes. In contrast, Coole et al. (2010) found that lower-back pain patients felt frustrated by GPs who immediately offered to sick-list them when they wanted to keep working.

Only so much can be understood by examining the knowledge, beliefs and expectations that doctors and patients bring to a consultation, because sick-listing is also affected by how stakeholders construct meaning through interaction within the consultation. There is some evidence that sickness certification for chronic pain conditions is not simply an unmediated response to physical pathology but a social process, to which the generation of shared meanings is central. These meanings may reflect legislation about who should and should not be sick-listed (Arrelöv et al., 2003), normative expectations regarding what is and is not an acceptable reason to be sick-listed (Meershoek et al., 2007), as well as the structural determinants described by Doyal (1979). The aim of our study was to explore how the structural tensions between the interests of chronic pain patients and the government’s objective of reducing sickness certification are played out at the micro-level of the GP consultation. Our questions were as follows: How do GPs manage the conflict between their role as patient advocate and gate-keeper to services and benefits? Is the evidence base on the health benefits of return to work sufficient to resolve this tension, or do sick-listing decisions remain contestable? What strategies do doctors and patients deploy to negotiate these decisions, and what do both groups think of the new policy initiatives?

Methods

Our assumption is that sickness certification is a socially negotiated process through which individuals invest their experiences with meaning; thus, our approach lies within the broad domain of symbolic interactionism which is concerned with how social order is maintained at the everyday micro-level of interaction (Blumer, 1986; Jeon, 2004; Mead, 1934; Starks and Trinidad, 2007). Structural factors and previously existing narratives provide the context, imperatives and constraints for the dynamic process in which meanings are negotiated and reworked. Direct observation of consultations was beyond the scope of the study, but we still wanted to access different ways in which sickness certification for chronic pain is experienced and made sense of by patients and doctors, and to capture a sense of how these meanings are generated, contested and negotiated. We judged qualitative interviewing to be the most effective way of accessing these meanings. The research was informed by Grounded Theory and the assumption that there are categories which help us to understand individual realities, making the shared creation of social reality possible and observable. There are different schools of grounded theory methodology (Charmaz, 2006; Charmaz and Henwood, 2008; Corbin and Strauss, 2008; Glaser and Strauss, 1967; Strauss and Corbin, 1990). Charmaz (2006) argues that there are so many schools that Grounded Theory Methods (GTMs) is a useful term for a collection of different methods with some similar principles which can be flexibly applied to research. We chose the constructivist branch of GTMs follow- ing Charmaz (2006) as we took the position that data are generated by research not merely collected.

Sampling and participants

We used purposive sampling to select information-rich participants (Patton, 2002). We collected data until saturation occurred, that is, until new data failed to generate new theory (Glaser and Strauss, 1967). Charmaz (2006) emphasises that this does not simply mean repetition of patterns but rather a point when no new theoretical insights into the main analytical categories emerge. The current investigation was part of a larger study that considers a range of issues associated with sickness absence. Data pertaining to GPs’ views on the fit note have been reported elsewhere (Wainwright et al., 2011). The current investigation focuses on tensions in doctor–patient relationships over medical certifica- tion, and has not been previously reported.

Participants were recruited in two groupings: practising GPs, and patients who had discussed sick-listing for chronic pain. A total of 13 practising GPs from 11 practices in the south-west of England were recruited at three GP training events and at practice meetings. In all, 30 patients were recruited by displaying posters in surgeries in south- west England, E.W. attending regional pain management services, and also nationally by placing a request for participants on UK pain charities’ web sites. The recruitment rate for the pain clinics was 24%. Three GPs and two patients withdrew prior to giving con- sent; no one withdrew afterwards.

There is some evidence that data saturation often occurs at around 12 interviews (Guest et al., 2006) and here saturation occurred among the GPs after 13 had been interviewed.

Patients’ experiences were more diverse and we judged that thematic saturation was not reached until 26 had been interviewed. Four more patients had already given informed consent, and it was deemed unethical not to interview them once invested in the study, so 30 patients were interviewed in total. The data of the last four were useful in confirming that saturation had been achieved.

All participants had to be at least 18 years old, judged by the research team as capable of giving informed consent and able to understand English adequately without an interpreter. All who expressed an interest in the study met these criteria. GPs were not screened as there were no other exclusion criteria for them. Patients were screened to ensure they met the following inclusion criteria. They had to

be in employment and have needed a sick or fit note within the last year, or on sick leave and require notes for wage-replacement benefits

have consulted their GP in the last year;

have experienced pain that had lasted for over 3 months within the last year;

consider that chronic pain was the major reason for sick-listing.

All participants were sent information packs at least a week before interview. Participant queries were discussed, and written informed consent was given by everyone prior to interview.

Procedure

Semi-structured interviews were chosen to encourage participants to raise issues salient to their experiences, generating rich, in-depth data (Denzin and Lincoln, 1994). Interview questions were developed to explore

how doctors decide if a chronic pain patient needs sick-listing,

what chronic pain patients consider when deciding if they need sick-listing,

doctors’ and patients’ awareness of and views on the government education programme that work is beneficial for many patients’ health outcomes, and also on the new fit note.

The questions were designed to reflect a symbolic interactionist approach, eliciting information about respondents’ experiences of the meaning of events. For example, a doctors’ question under topic 1 was ‘How do you make sense of whether or not your patient should be signed off?’

A pilot study with two doctors and two patients was conducted. Field notes and memos were written after each 60 minute interview following Patton (2002) and Charmaz (2006). Participants chose to be interviewed face-to-face or by telephone. No participants were paid. All interviews took place following the introduction of the fit note in April 2010. Interviews with doctors were conducted from April to October 2010, face-to-face in their surgeries, every doctor’s preference. Interviews with patients were conducted from April to October 2010. A total of 27 out of 30 patients were interviewed over the phone as they lived all over the United Kingdom.

Analysis

Interviews were audio-recorded, transcribed and coded. GTMs principles were followed for data analysis (Charmaz, 2006; Green and Thorogood, 2004). One researcher used open coding to generate potential codes, accompanied by verbatim quotations. Constant comparison was used to interrogate initial codes, organising them into analytical hierarchies until core categories were established. A second researcher took a selection of the quotations and categorised them into the previously identified core concepts. Differences in interpretation were discussed until consensus was reached. NVivo 8 software was used to organise the analysis.

Ethical approval

National Health Service (NHS) ethical approval was given by Bath Local Research Ethics Committee (09/H0101/72) and the Departments of Health and Psychology Ethics Committees, the University of Bath.

Results

Data analysis revealed three core themes. First, for doctors, the main issue was the double uncertainty of managing medically unexplained symptoms attending many chronic pain conditions, coupled with mapping these onto capability decisions. Second, for patients, sick-listing was perceived as a struggle to achieve state-sanctioned legitimacy. For both parties, these issues disrupted ideal doctor–patient roles, which were partially restored by sick-listing. Third, doctors and patients agreed with the rationale underlying the policy initiatives, as they believed in the health benefits of work, but found it prob- lematic to apply this to some of their own situations, which they believed had particular elements not accounted for by the general principle that work is good for us.

We will now look in detail at issues that arose within each theme.

The doctor’s dilemma: double uncertainty

Many symptoms encountered in general practice, including chronic pain, challenge traditional assumptions about mind–body dualism and blur the distinction between subject and object. Thus, the nature of the illness and the appropriate course of action cannot simply be deduced by an examination of physiological signs and symptoms but require engagement with the patient’s account of the illness:

Building up experience of patients’ enactment, is how we benchmark the particular patient’s pain in front of us … some patients hunch and guard and some have learned to accept [their pain] so it’s harder to gauge their level of pain. But it’s a bit like gauging other things like depression, we take a history, listen, look, use our professional judgment. (GP 11)

Many doctors reported that assessing patients’ pain was challenging and uncertain: ‘in the end, it comes down to the patient, and some are not as eloquent as others’ (GP 8).

This led to ‘intellectual discomfort’ (GP 6) for some doctors as they were uncomfortable making capability decisions without biological evidence of pathology. Uncertainty about diagnosis was compounded by ignorance of patients’ working conditions; this double uncertainty rendered decisions about capability for work challenging:

It’s extremely difficult because you can’t see somebody’s pain. Quite often the patients just bounce into the surgery and don’t look like they’ve got pain at all … they’re the problem ones. They say they’ve got agonising back pain and can’t possibly work, but there’s no objective evidence … (GP 2)

and … the trouble is, of course, as a GP, I don’t necessarily know much about their work. (GP 6)

Even doctors with OH qualifications reported that

There’s factories and there’s factories, there’s shops and shops … some of the shops have nice, wide, light, airy aisles and every manual handling device you can imagine whereas … the charity shop you go up and down three flights of twisting stairs, carrying boxes as you go. (GP 13)

In response to uncertainty, doctors valued ‘listening to the patient’ (GPs 1, 11 and 13) and trusting how they described their jobs. Most doctors trusted most patients’ accounts: ‘I don’t think people set out to mislead us, it’s not in their interest’ (GP 13) but also said a minority of patients’ reports of their jobs could be skewed: ‘There are some patients who basically have jobs that they didn’t like at the best of times … that’s where the problem lies, the motivation to return is poor’ (GP 9). In these cases, sickness certification can allow both parties to feel (at least superficially) that the consultation was successful. The doctor may give the note, but with provisos, such as making the absence period short. The note then takes on symbolic value as a declaration that the doctor listened to the patient and acted sympathetically. The ‘achievement’ (GP 11) of obtaining a sick note can enable patients to believe that their illness has been validated and their work absence legitimated, thus offering a sick note partially restores the doctor–patient relationship as patients obtains doctors’ help. However, doctors often reported dissatisfaction with the lack of objective evidence behind decisions and were concerned that limited treatment options led to unsatisfactory outcomes:

There’s nothing that we can offer people other than X [a specialist pain clinic] and let’s face it X is very oversubscribed. The trouble is also once they’ve been through that system then they come out the other side and maybe they’re better for a bit but inevitably they come back here again and then what do we do? There’s no on-going input. (GP 8)

Withholding a sick note could generate conflict with patients, disrupting the ideal Parsonian doctor (Parsons, 1951):

I certainly don’t think it’s right for GPs to put themselves in the position of judgement and it’s amazing … the percentage of patients who feel threatened by that, and I feel uncomfortable that we need to do it, to some degree. (GP 5)

Other doctors related their unwillingness to refuse a note to their conviction that this is not their job, as they need to privilege their on-going relationship with patients:

I think ultimately if they want a note, they’ll get it. I might try and persuade them back to work and advise them that perhaps it’s in their interest but there are some people who are determined to have it and then I don’t see it as our job to stop that. I know that they’ll be assessed by a benefits doctor and they’re not looking for a long-term relationship with the patient. I suppose I’d begrudgingly give the note in the knowledge that there’s another doctor who’s independent and doesn’t have that long-term relationship who will actually make a judgement … whether they’re fit or not. (GP 13)

Some doctors were more assertive, managing to set targets while still maintaining that they would not refuse to sick-list:

I would never refuse a note as then we get into a situation of conflict and that’s no good for anyone as someone has to back down and lose face. It’s about managing expectations. I’d give shorter and shorter notes and I’d say in one consultation that the next note would be shorter, so I’m setting up that situation. (GP 10)

Strategies doctors discussed included contacting employers to facilitate targeted support for patients (which got little response), and emphasising the health benefits of work, but notice also the reference to ‘managing expectations,’ suggesting an active process of renegotiating meanings.

Some doctors claimed that the government was asking them to police the benefits system whereas that was not what they felt doctoring should encompass. Such policing involves making moral judgements which some doctors felt uncomfortable about. An in vivo code ‘I’m not a health policeman’ (GP 8) encapsulated this and many doctors said they were the patient’s advocate: ‘I’m not going to send them back if I think that will make them worse, whatever the DWP or anyone else says’ (GP 4).

The uncertainty entailed in sick-listing for non-specific complaints elicits a range of different responses from doctors: acquiescing to patients’ wishes, attempting to impose provisos, trying to change expectations or simply refusing what they see as a policing role. Adoption of these strategies is often accompanied by feelings of dissatisfaction.

Patients’ experiences of sick-listing: a struggle for validation

The uncertain nature of chronic pain made sick-listing consultations challenging for patients as well as doctors; most were confident they would eventually get a sick or fit note if they wanted one, but often felt delegitimised by the process:

I must admit I’ve routinely made damn sure somebody does see me when my back is bad, because I think it’s just too easy to … you know, to wait till you’re better and then go down the doctors’. I talk to fight, if you know what I mean. But then you realise underneath, actually I wish I wasn’t fighting. (Patient 1)

Patients are aware that the legitimacy of their complaint can depend upon how they present their symptoms to the doctor, but the intermittent nature of chronic pain coupled with waiting for appointments means that they often present when their symptoms are in abeyance. On these occasions, the patient is obliged to enact the severity of their condition to persuade the doctor that they are genuinely ill: ‘Unfortunately the system makes people do that, you’ve got to demonstrate your worst days’ (Patient 1). Having to (re) enact their symptoms in order to be signed off is a risky strategy. If the performance is unconvincing, it might be read as evidence of illness deception. Even if the performance is convincing, it may leave the patient feeling as if he or she has engaged in some kind of fiction.

Patients often believed that their reports and enactments of pain were not fully trusted by doctors, giving rise to a mutual process of scrutiny in which the doctor surveys the patient for clues as to the authenticity of the illness and the patient returns the doctor’s gaze looking for signs that he or she has not been believed:

I didn’t like my GPs before – I just didn’t like the face that they pulled, like, ‘Oh, again’. They would do the note but I would leave their practice with a very guilty feeling and I was feeling like a criminal sometimes … [the pain] was real … I looked healthy, but it was true. (Patient 6)

The need to ritually re-enact the outward appearance of pain in order to persuade a sceptical doctor of the validity of the illness claim can move a consultation away from the Parsonian ideal types of stoic resilient patients and sympathetic and caring doctors:

He’s written fibromyalgia down as well on it [the note], ticked ‘you may be fit for work taking account of the following advice’, then he’s ticked ‘amended duties’. Now that’s because when I went, he said, ‘Is it any better?’ I said, ‘From how it was, yes, but it isn’t right. It still keeps swelling up and everything else’. As you’re talking to him, it’s almost as if he just doesn’t want … to listen … it’s almost as if … if you’re not committing suicide, he doesn’t want to know. If I sat there in floods of tears and was screaming and shouting and everything else, perhaps he’d take more notice. (Patient 20)

This is likely to make the patient feel fraudulent, even if he or she is only enacting pain that really is present on other occasions. This account also exemplifies how being refused the ‘not fit for work’ box led to patients feeling stigmatised as they perceived their accounts were trivialised. Whether or not patients wanted sick-listing, there was tension around the subjectivity of chronic pain, as patients thought that their own accounts should be an important part of the sick-listing process, but they did not see these accounts being recognised as central.

Doctors’ and patients’ accounts reveal that a lack of observable biological evidence about patients’ illnesses and doctors’ lack of knowledge about patients’ workplaces can generate uncertainty, mutual loss of trust, and conflict in the doctor–patient relationship, all of which can lead to inappropriate sick-listing and other negative outcomes.

Will the recent policy initiatives work?

Doctors’ views solely on the fit note have been discussed elsewhere (Reference X). Here, we not only report doctors’ views on the central concept of the national education programme that work is good for our health and well-being, followed by patients’ views on this and the fit note, but also explore the fit between the policy initiatives and the practical task of improving sickness certification.

The national education programme was broadly welcomed in that all participants agreed with the concept that ‘safe and accommodating’ work is good for us (Waddell and Burton, 2006: ix). However, many doctors characterised patients’ working environments as stressful, and discussed how they would be more inclined to sick-list people thus affected:

I mean most of the time I think work can be therapeutic – it’s better to get back to work and be normal. But for some people, work is the issue, so then I write them a sick note. (GP 12)

In addition, even when a doctor believed that a patient might be better off returning to work, he or she often found difficulty in arguing strongly for this course of action if the patient was wary or unwilling, largely because the doctor did not wish to appear unsympathetic. One GP maintained, ‘If people with chronic illnesses can be normal, it really helps; having a job is a normal thing to do … [but] I’m soppy soft’ (GP 6). Getting patients to follow a potentially beneficial course of action that they are strongly opposed to can be a difficult task for doctors. It goes against professionalised narratives that emphasise the importance of partnership in the doctor–patient relationship, such as ‘concordance’ and ‘patient-centred practice’. However, some doctors were able to negotiate return to work even among resistant patients, not exclusively by reciting the evidence base, but rather by implementing tacit methods of persuasion and coaxing that they had developed over the course of their practice.

Patients did not usually need to be persuaded of the benefits of work in abstraction, but rather in relation to their own particular symptoms and circumstances. Thus, in principle, work was viewed positively, because ‘people feel absolutely worthless, without work’ (Patient 27) and many patients discussed the financial necessity of working. All the patients with jobs reported making great efforts to overcome challenging barriers (such as the fluctuating and often unpredictable nature of chronic pain, dealt with by flexi-time where possible) because they valued their work financially and socially. Nonetheless, patients also talked of personal experiences which made work extremely difficult:

I’m currently managing to work full-time but at the complete expense of my social life. I’m always resting to recover from work and to ensure that I can work again the next day … just wanted to make it clear that there’s a price to pay for determination to carry on! (Patient 19)

This patient was trying to stay in work because she valued it and elsewhere she discussed avoiding the stigma of not having a job. However, she also appeared to be suffering, and her identity as a capable worker and as someone able to fully participate in life was spoiled Goffman (1968) even though her physical pathology was not impeding what she did at work.

We found some evidence that the way in which recent policy initiatives are being framed could generate negative responses that might impede return to work. For instance, some patients were sceptical about the promotion of the benefits of work, viewing it as secondary to the political goal of reducing the social security benefits bill:

If I wasn’t claiming any money from anybody, nobody would care. They wouldn’t talk about the benefits of working and benefits to society they wouldn’t give a stuff about these things. What it boils down to is money. The rest of it is just kind of fancy rhetoric. (Patient 1)

These patients felt pressurised by what they viewed as harsh government policies which posit sick-listed people as malingerers. If patients perceive return to work as a politically motivated drive to cut welfare costs, rather than a means of genuinely improving their lives, there is a danger that further absence from work will be constructed as a form of ‘political resistance’ to austerity measures and a means of preserving hard-won benefits and entitlements. Other patients viewed the policy initiatives more positively, for instance, valuing the shift in emphasis from incapacity to capacity for work, and the pos- sibility that the recommendations given in a fit note might encourage employers to pro- vide more support for return to work:

My employers will see what I can do more clearly … I’m hopeful this might help me get more targeted support … I need some steps [to reach shelves] then I can do more, so maybe my GP can say that, or maybe my boss can change my duties a little bit. (Patient 28)

Although some patients hoped that the advice given in the fit note would make their employer ‘sit up and take notice’ (Patient 19), because of the primacy accorded to medical knowledge, others were more sceptical and did not perceive that the fit note would make any difference to them. Not because the advice contained in the fit note was necessarily wrong, but because the likelihood of the measures being implemented was constrained by the need to maximise productivity and other demands of the work- place, rather than by the employer not knowing what should be done or requiring a push from the GP.

Discussion

Beyond the knowledge-deficit model and naïve rationalism

There is compelling evidence that much sick-listing is unnecessary and that many patients signed off sick would do better if they remained in work. Successive UK governments, keen to curb the costs of sickness-certification rates, have asked why doctors continue to issue sick notes on demand when the evidence base suggests they should do otherwise. The answers that policy-makers have developed are largely based on the assumption that doctors and patients are simply unaware of the evidence that work is good for us and that most people can return to some form of work when they are less than 100% fit, providing their duties are appropriately amended and/or additional adaptations to the workplace are made. This assumption is based on the rational expectation that when doctors know what is best for patients they do it, and that if patients are aware of this too they will gladly comply. After Russell et al. (2008) we would characterise this approach as ‘naïve rationalism’.

Our findings challenge the adequacy of the knowledge-deficit model. Our interviews with doctors and patients reveal that sickness certification is not, and arguably cannot be, based solely on the evidence base relating to the likely outcomes of different management strategies. For non-specific or medically unexplained symptoms like many chronic pain conditions, physiological evidence does not provide a basis for diagnosis, prognosis or management at the level of the individual patient. Instead, we found that the doctor and patient are confronted by uncertainty, and decisions about capability and return to work are influenced by less rational factors, including the patient’s ability to enact pain convincingly, the doctor’s capacity for empathy, and competing notions of entitlement, obligation, sympathy and trust. These narratives exist prior to a sick-listing consultation (Eccleston et al., 1997; Van Oorschot, 2000) and our findings imply that they do not determine its outcome in a mechanistic or predictable way. Instead, we suggest that sick-listing depends upon a process of social negotiation, often comprising conflict and competing claims, as patient and doctor strive to construct a narrative about the ‘validity’ of the illness and what it means for the patient, specifically with regard to capability for work.

Sickness certification may be multifactorial and unpredictable, but beneath this appearance of complexity, we argue that appropriate sickness certification is in part a function of the quality of the social relations between doctor and patient. Where these relations are characterised by mutual lack of trust and empathy, or by a structural conflict of interests, developing and implementing a strategy for return to work is likely to be problematic, no matter what the evidence base might say about the likely benefits of doing so.

Tacit skills and ‘practice-based evidence’

A central finding of our research is that the sickness-certification process for patients with chronic pain is dominated by uncertainty: uncertainty about the nature and severity of the illness, the patient’s capability for work, the authenticity of the illness claim and the likely outcome of returning to work. These uncertainties could give rise to mutual mistrust and conflict as both parties struggle to negotiate their own definition of the situation. The issuing of a sick note can often be a means of managing this conflict, going some way to restoring the patient’s belief that the doctor recognises the validity of his or her illness claim, is sympathetic to his or her difficulties and is prepared to act on his or her wishes. This partially restores the disrupted order of the clinic (Strong, 1979). However, even when a sick note is issued, either party may remain partially dissatisfied. The doctor may feel that the patient could and should have returned to work and that the decision to issue a sick note was unprofessional and not in the best interests of the patient. The patient may be left with a residual feeling of inauthenticity from the need to display the symptoms of pain and a suspicion that the sick note has been issued grudgingly or against the doctor’s better judgement.

Some of the doctors we interviewed reported that they had developed more effective responses to the uncertainties and tensions of the sick-listing consultation, for example, issuing sick notes, but reducing their duration or actively trying to change the patient’s expectations and beliefs about their illness and capability for work.

These strategies often comprise tacit skills for establishing trust and empathy and coaxing the patient to consider the possibility of returning to work. The latest iteration of the sickness-certification training programme for GPs acknowledges the role played by these tacit skills and attempts to propagate good practice with regard to them. These training programmes have been successful not only in promoting GPs’ awareness of the contribution work can make to health outcomes but also in equip- ping them with negotiating strategies to manage sometimes challenging consultations (Cohen and Black, 2013). Our findings support this shift of emphasis; it is difficult to change beliefs and behaviour in relation to back pain, and it has been suggested that multifactorial approaches are the best (Gross et al., 2012). We suggest that doctors’ tacit knowledge/skills should be more extensively studied in relation to sickness certification, to produce a body of ‘practice-based evidence’ that might move us further beyond the knowledge-deficit model towards a model of doctor–patient negotiation and persuasion. Policy-makers could also explicitly acknowledge difficulties regard- ing the structural and discursive context in which sick-listing consultations occur, particularly the dilemmas that arise as a result of the doctor’s dual role as patient advocate and gate-keeper to services and benefits. This tension can corrode trust in the doctor–patient relationship and fuel an ongoing struggle for legitimacy (Nettleton, 2006), in which the patient feels obliged to enact symptoms which at the moment of the consultation might be in abeyance, and the doctor feels equally compelled to scrutinise the veracity of the illness claim.

Conclusion

The desire of successive UK governments to reduce sickness certification and enable more patients with chronic pain to remain in work may improve the health and well-being of patients, reduce costs to employers and the tax-payer and even effect greater social justice. However, tensions remain and the likely effectiveness of current policy interventions might also be limited by the adoption of a knowledge-deficit perspective which assumes that inappropriate sick-listing is largely a function of ignorance of the evidence base relating to the benefits of remaining at work. Sorting those who should remain at work from those who should not is a far more complex process than it may appear. Evidence from practice has a role to play, and our findings suggest that there are other social, economic and psychological factors that impact the negotiation of sickness certification. The most recent policy and training materials are beginning to recognise this, emphasising the need to equip GPs with the rhetorical and persuasive skills to address such issues, although they could go further. Future research should focus on the efficacy of these skills in promoting return to work and assessing the extent to which they can be codified and shared through training and professional development.

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