Sick notes, general practitioners, emergency departments and fracture clinics

Abstract

Background

General practitioner waiting times are increasing. The two national surveys regarding general practice showed that the number of patients waiting for ⩾2 days for an appointment rose from 63% to 72% between 1998 and 2002, with 25% waiting for ⩾4 days. The Department of Health recognised that many patients discharged from hospitals and outpatient clinics required to visit their general practitioner for the sole purpose of obtaining a sick note. The report entitled Making a difference: reducing general practitioner paperwork estimated that 518 000 appointments (and 42 000 GP h) could be saved by ensuring that these patients were issued with a sick note directly from hospital rather than being referred to their general practitioner. This practice was to be adopted from July 2001 and included patients discharged from wards as well as those seen in outpatient departments.

Method

50 emergency departments and fracture clinics in Scotland and England were contacted to assess whether these guidelines had been adopted. Only hospitals with both accident and emergency and fracture clinics were included; nurse‐led and paediatric departments were excluded.

Results

Of the 25 Scottish emergency hospitals contacted, 4 (16%) accident and emergency departments and 8 (32%) fracture clinics issued sick notes. This was compared with 5 of 25 (20%) accident and emergency departments and 12 of 25 (48%) fracture clinics in England. Four Scottish and five English accident and emergency departments stated that it was policy to give sick notes, three Scottish and four English departments said that it was policy not to give them and the rest (72% in Scotland and 64% in England) stated that they had no clear policy but “just don't give them”.

Conclusion

The 2001 guidance from the joint Cabinet Office/Department of Health has not been fully incorporated into standard practice in Scotland and England. If all emergency departments and fracture clinics were to issue sick notes to patients requiring >7 days absence from work, this could reduce general practitioner consultations and improve waiting times.

General practitioner waiting times are increasing. The two national surveys regarding general practice showed a 9% increase in the number of patients waiting for >2 days for an appointment (from 63% to 72%) between 1998 and 2002, with 25% having to wait for >4 days.¹ In 2005, there were approximately 15.7 million general practitioner consultations and 27.4 million face‐to‐face contacts between patients and members of the practice team in Scotland alone.²

Obviously, measures to reduce general practitioner waiting times are important.

When patients attend emergency departments, some will have conditions that require a period of absence from work. Patients attending fracture clinics, especially, often have conditions that leave them unable to perform their normal work activities and require a period of convalescence. The doctors who initially diagnose and treat such patients are generally better placed to estimate the time off work required for convalescence and, if such doctors were to issue sick notes at the time of initial contact, subsequent general practitioner attendances may be unnecessary.

The Cabinet Office report entitled Making a difference: reducing general practitioner paperwork estimated that 518 000 appointments (and 42 000 GP h) could be saved by ensuring that all those who required a sick note were issued one from the hospital rather than being referred to their general practitioner.³,⁴ This practice was to be adopted from July 2001 and included patients discharged from the wards and those seen in outpatient departments.

The aim of this study is to assess whether emergency departments and fracture clinics in the UK are issuing sick notes in line with the above guidance.

Method

We contacted 50 emergency departments and fracture clinics in Scotland and England to assess whether these guidelines had been adopted. We asked whether the departments issued sick notes and whether they had a clear policy regarding sick note provision. Only hospitals with both accident and emergency and fracture clinics were included, with nurse‐led and paediatric departments excluded.

Results

Of the 25 Scottish emergency hospitals contacted, 4 (16%) accident and emergency departments and 8 (32%) fracture clinics issued sick notes. This was compared with 5 of 25 (20%) accident and emergency departments and 12 of 25 (48%) fracture clinics in England.

In all, 4 (16%) Scottish and 5 (20%) English accident and emergency departments stated that it was policy to give sick notes; 3 (12%) Scottish and 4 (16%) English departments said it was policy to not give them and the rest (72% in Scotland and 64% in England) stated they had no clear policy but “just don't give them”. In all, 68% of Scottish and 52% of English fracture clinics surveyed stated that it was policy that patients had to see their general practitioner if they required a sick note.

Discussion

Obviously, the 2001 guidance from the joint Cabinet Office/Department of Health has not been fully incorporated into standard practice in Scotland and England.

There are a few reasons for this.

Firstly, many patients believe that only their general practitioner can issue sick notes and therefore do not ask for one from another doctor. This is understandable, given the current practice. Some doctors also believe this to be the case.

Secondly, individuals are able to self‐certify absence from work for 7 days. Doctor‐prescribed sick notes are required only if sick leave exceeds this period. Doctors may be (understandably) reluctant to issue sick notes if they feel that they may not be required.

Time factors are also important. It is simply faster for an emergency department doctor or orthopaedic surgeon to say, “Go to your GP if you require a sick note” than to take the time to complete one personally. If no policy exists stating that sick notes should be completed for all patients who will require them, then there is little onus on the accident and emergency or orthopaedic teams to add to their own workload.

Emergency doctors may also believe that if they were to start issuing sick notes, then some people may attend their department (rather than their general practitioner) for the sole objective of obtaining one. This could be avoided by making it clear that sick notes are given only to patients with orthopaedic injuries who will definitely require >7 days of absence from work. If the convalescence period is in doubt, then patients should attend their general practitioner after that time if further sick leave is required.

Accident and emergency doctors may not be issuing sick notes as they know that their patients will be seen in the orthopaedic clinics, where the surgeon will have a better idea of sick leave requirements. The problem is that many patients are attending these clinics and still are not being issued sick notes. If both departments made it their policy to issue sick notes, then hopefully fewer patients would have to needlessly attend their general practitioner.

Conclusion

Many emergency departments and fracture clinics have not yet adopted the 2001 Department of Health guidelines for sick notes provision into standard practice.

Departmental policy should make explicit the guidance that all patients with orthopaedic injuries who will require a period of sick leave >7 days should be given a sick note before leaving the department. This should help reduce unneeded general practitioner consultations and improve waiting times.