Why the health secretary’s “well note” is not so swell

Everyone agrees that the United Kingdom’s state benefit system is in a mess. The cost to the taxpayer has escalated out of control, and the annual bill is now in excess of £13bn (€17bn; $26bn). The public are outraged by stories of malingering and inappropriate claims, and the government has appointed Carol Black, as national director for health and work, to investigate alternatives to the current flawed system.

Most GPs would like to be removed from their current central role in signing patients off work—not because we are lazy, but because we recognise that it is impossible to be the patient’s advocate on health matters at the same time as being responsible for deciding whether they are entitled to incapacity benefit. Furthermore, most of us have no experience of occupational health and really know little more about our patients’ work environments than anyone else. Instead of policing the system effectively, honest GPs admit that they nearly always simply ask their patients whether they think they should be at work and how long they think they should be off work. At most we may suggest that work is generally good for health and that usually you don’t need to be completely fit before returning.

It is the naive assumption that GPs can police the system, together with one of the lowest levels of occupational health advice in the European Union, that accounts for the UK’s current problem. I estimate that I have signed about 20 000 people off work in my career so far, yet I doubt that I have ever made any significant useful contribution. Talking to other GPs shows that my experiences are shared. I have yet to meet a GP who would be prepared to fall out with their patient over this. Besides, what could a GP gain by insisting that patients return to work against their wishes? At best, an upset patient; at worst, the likelihood that the patient would seek further opinions or even sue the GP if any perceived harm resulted from returning to work prematurely. Interestingly, most employers would like to scrap the present system as well. It is the unions, representing the employee, that are most eager to maintain the present system. Why? I am amazed, though, how few employers ever challenge a certificate or seek further information, even when it is blatantly inappropriate for their employee to be signed off.

Sadly, rather than acknowledge this straightforward fact, health secretary Alan Johnson now somehow imagines that GPs will be able to extend their role and start to provide “well notes” (see News doi: 10.1136/bmj.39503.348032.DB). This lack of insight into the relationship between patients and their GPs and the blinkered insistence on maintaining the current failing system are lamentable.

For the 60 years of the NHS, patients have had in their GP a trusted health adviser and advocate. Ninety per cent of doctor-patient encounters are in primary care, and the modern GP manages complicated, multisystem diseases with the benefit of a long term relationship. Remarkably, this government seems hell bent on destroying this arrangement, once described as the jewel in the NHS crown. The introduction of Ara Darzi’s polyclinics (BMJ 2007;335:61 doi: 10.1136/bmj.39273.467697.DB), a matter of utmost priority for this government, will seriously undermine existing primary care. But far more alarming will be the insidious destruction of any opportunity for GPs to maintain long term relationships with patients and thus to be able to encourage them to return to work, particularly against their wishes. Nothing would stop patients shopping around until they found a doctor willing to accept the reward of a simple consultation and the offer of an off-work certificate. The introduction of a parallel private system, intended to undermine current primary care, will render this new role completely impossible.

The solution is straightforward. GPs should be removed from their central certifying role, and properly independent occupational health services should be made available to all employees. With £13bn to play with, this should be eminently affordable. As a GP in a town with about 30 GPs, not only do I have no real concept of the issues in a workplace, but I also have only a very small part of the whole picture. My town has about 30 GPs. An occupational health adviser, working with all the doctors and practices, would see trends in the workplace that could never be apparent to one GP, whose main interest is only the patients he or she looks after. The only role for a GP then would be to provide an occasional factual statement of a medical condition, perhaps with some functional interpretation if necessary. Deciding whether the patient is capable of some work, or any work, could then be made by the occupational health adviser, who would have insight into the work environment, an opportunity to make changes, and, crucially, no ongoing commitment to the employee in a caring role.

Perhaps, more controversially, employees who are off work could be fast tracked through secondary care for investigations and treatment, if their return to work is delayed by a medical condition.

Until we start to think in such radical ways the problem will only deteriorate. GPs are already angry over demands to increase patients’ access and feel undermined by Lord Darzi—this is hardly the time to ask us to take on a difficult task that we have already demonstrated cannot be done.

I estimate that I have signed about 20 000 people off work in my career so far, yet I doubt that I have ever made any significant useful contribution

GPs should be removed from their central certifying role, and properly independent occupational health services should be made available to all employees