General practitioners and sickness absence

Currently, it works like this.

If you are ill and unable to work, you sign yourself off work for the first 7 days. This is self-certification.

After this, you need a doctors’ line – the so-called Fit Note. This is a certificate from the doctor to say that you are currently unable to work due to illness. There is now a space in the form for the doctor to say if you can work with amended duties, for example, seated duties only, or a return to work gradually with a build up to usual hours.

This line can be for days to months. After 28 weeks, the patient is goes on to ESA (Employment Support Allowance). The first phase lasts 13 weeks and is an ‘assessment’ phase’. By week 14, a Work Capability Assessment has been done. From there, the person can be refused further ESA and put onto job seekers allowance (unemployment benefit) instead. Or they can be given an extra ‘component’ of funds if the assessment shows they are unfit to work.

The assessments for ESA are currently done by Atos. The assessment is done without full access to the patient’s notes. The questions ask about best days, not worst days, and do not take into account the variability of conditions. If you have the Citizen’s Advice Bureau helping you with your appeal, you are 70% likely to win your appeal for Disability Living Allowance; otherwise you are 60% likely to succeed without an advisor. One may reasonably conclude that a successful appeal rate of this magnitude questions to accuracy of the assessments.  Atos is a French electronics company, who employ doctors, nurses and physiotherapists to fill in computer-based forms. Atos have previously refused to answer my polite questions about how they train their staff and audit them, and about the evidence base for their questionnaire.

In the last couple of days, the news is that “People should be signed off for long-term sick leave by an independent assessor rather than their GP, a government review will recommend.” On the Today programme last week, Lord Freud said “At a certain point, that is, around 4 weeks, it’s important that there is an independent look to see what can be done to help people back into the workplace. Because that’s the point at which you can get into drift. If you start having have no support at all for the next 28 weeks…a very large proportion of people who then drift off into state support and very long term support, which is quite unnecessary in many cases.”

Is this true? Freud presumes that people have no support between 4 and 28 weeks of sickness absence. This isn’t true. GPs are responsible for reviewing these patients and ensuring that whatever it is that is keeping them from working is being treated, and that they are appropriately not working. The usual practice is to sign people off for a few weeks at a time.

The Fit Note, meantime, has no legal standing in terms of what the employer should provide. So if I say ‘suitable for mainly seated work’ the employer can say no, and the person cannot return to work. Or if I say ‘graduated return to work, start mornings only’, the employer can say no, and the person can remain on sick leave.

Freud believes that people off at 4 weeks are at very high risk of never working again. The idea, according to the Independent, is that a new independent body will see patients at 4 weeks and decide whether or not they should still be off on sickness absence. Freud says that the question will be asked “Can you do any job?”

The current sick notes are based on whether a person is fit or not to do their current job. My suspicion is is that the new scheme will assess ability to do any job. We haven’t been told if it will be a private company like Atos who will be charged with providing this new service, or how the assessments will be done, or what evidence there is for getting people back to work once they have had the assessment. How much will this company be paid, and will they be told to get a certain percentage of people back to work – just as Atos has been told to do? I am also concerned that this new scheme will make vulnerable people worried and anxious about failing the assessment.

I have no doubt that there are some people who are on long term sickness benefit who are capable of some kind of work. From my perspective though, this group is a minority. Most people want to work, for economic as well as personal reasons, and many people whose illness renders them unfit to work are scared about losing their job as well as frustrated that they cannot work.

What worries me about the review and Freud’s interview is the presumption that the majority of people on long term sick leave are fraudulent and/or capable of working. This hasn’t been borne out by ESA assessments, which have found that only about 1 in 3 people on long term sick leave are fit for work.

GPs are not occupational health doctors. But GPs often know patients well, and also know the advantages of work over unemployment. Equally, though, sickness means that some people cannot work. I am concerned that this isn’t being accepted by government – in the same way that the NHS is being disparaged for being a ‘national sickness service’. Of course it is – and of course, sometimes, through sickness, people cannot work.

The one thing that sounds like good news for employees with chronic illness – tax breaks for their employers – could be overshadowed by the presumption that sickness absence is always, or usually, inappropriate. It’s sometimes necessary, and a decent society should ensure that we care for sick people with sensitivity and respect. Removing GPs from sanctioning all sick leave needs of longer than 4 weeks seems both bad for patients and an overstatement of the misuse of the forms.

And what’s really irritating is that the publicity has not been accompanied by release of the policy.



11 Responses to “General practitioners and sickness absence”

  1. Kim Holt November 20, 2011 at 12:30 pm #

    I became unwell in 2007 due to work related stress; essentially depression due to overwork in a hostile environment. I was signed off by my GP reluctantly but then occupational health were equally concerned about my treatment and lack of support for doctors within the department. Indeed two other consultants had resigned less than a year before I went on sick leave. When I went on sick leave I was accused of malingering by my manager, and the attitude was that I should sort myself out and get back . Management refused any meetings with occupational health and then suddenly ( after baby P had been seen by a locum) I was offered 80,000 to leave and the work related stress was used as the main reason. This I tell you only to highlight that managing illness in the workplace depends upon employers that are willing to follow good practice. It is very hard for staff who do not get the support that they need. Will the independent assessors have some clout to ensure that the support is there? Kim Holt

  2. Alan Henness November 20, 2011 at 1:19 pm #

    …a decent society should ensure that we care for sick people with sensitivity and respect.

    Absolutely. It looks like society will be left to do the caring and the supporting and that the Government (and many employers) wants to have no part of it.

  3. James Bowden November 21, 2011 at 10:09 am #

    I would like to discuss the nature of the tests that are being utilised with Margaret if she would contact me please
    The essence of the discussion is that the scientific basis for the assesments is flawed and this needs to be propely aired
    Once properly informed lawyers are avaialble they will have a hay day winning cases for their clients
    Once again we are being let down by our Government – the Government – should focus on presenteeism – not absenteeism – presenteeism carries up to seven times the cost of abseenteeism to industry

  4. DeusExMacintosh November 21, 2011 at 2:19 pm #

    Freud says that the question will be asked “Can you do any job?”

    So will we be seeing a return to the old Parish Relief of the 1930s which could include a VIRGINITY TEST (presumably on the basis that if you failed it you were qualified to prostitute yourself for a living)?!

  5. Margaret McCartney
    margaretmccartney November 21, 2011 at 7:38 pm #

    dear James, my email is

    I think you are right Kim, I think better connections need to be made between OHS and GPs, but the answer is not an atos-like instrument taking precedence over what happens – especially after just a few weeks of sick leave.

  6. Paul Smith November 22, 2011 at 4:36 pm #

    What really angers me about this is the fact the government are basically saying we don’t trust GPs anymore.

    The government say that GPs are sometimes harrassed into providing a sicknote, I personally don’t believe this and If it is happening then the GP needs to take a close look at his or her practice.

    As someone who runs a website for people who encounter problems etc with Atos and the DWP I am continually being contacted by people with severe medical problems, they are telling me that their own GPs and hospital consultants have told them they are presently unfit for work and in many situations may never work again, then they are being assessed fit for work by someone clicking answers on a computer screen, these people have not seen the medical records of these people, they cannot have the expertise of the persons own GP. I find it very worrying that the bodies that represent doctors/GPs etc have not made formal complaints to the government in regard to how the government is promoting a picture of GPs in a false light, it’s bringing the profession of GP work into disrepute, it’s basically telling the world your all incompetent?

    If I were a GP I would be very angry by the insinuation that I don’t know or understand my own patients abilities regarding their health, are we likely to see the relevant organisations which represent GPs stand up against the government and more importantly stand up for their patients????

  7. Mark Struthers November 22, 2011 at 9:32 pm #

    John Harris from the Guardian wrote yesterday about the new ‘sickness absence review’ and this wretched government’s attitude to those unfit to work. His piece is titled,

    “Stop targeting this imaginary army of long-term sick. The sickness absence review will only lead to incapacitated people limply tramping the streets looking for nonexistent jobs”

    A lady called ‘cowgirl’ – on page 10 of the comments – caught my eye. Cowgirl said,

    “I met a woman last week who has worked all her adult life and is now in her late 50s. She was hobbling painfully after a hip replacement and is waiting to be well enough to have her other hip done in the new year. On the day she went into hospital she had a letter saying that ATOS had assessed her as fit to work- she told me she cried throughout her hospital stay as she was so worried about having no money. It is, of course, ridiculous to imagine that she should come out of hospital and sign on as a jobseeker the next day, but what else was she being expected to do? Is this really what the government want?

    There seems to be a chasm between their perception and reality- how can we make them see how misguided they are? Of course, they may be all too aware of what their policies mean for seriously ill people, and are determined to press ahead anyway. What does that scenario say about this government? So the conclusion is they must be either very stupid, or very evil. Which do you think it is?”

    What do you think, Margaret?

  8. Guy Pedliham November 24, 2011 at 12:58 pm #

    Having had the “pleasure” of contact with Atos I have to wholeheartedly agree with you.
    First of all the computer programme that was being used had no way of taking into account the nuances of my illness. Which is not helped by the fact that staff stuck slavishly to using this tool.
    The nurse conducting my “assessment” made virtually no eye contact with me at all. I think that was her personal style anyway but also because she was too busy typing away. She clearly did not even have a working knowledge of my particular illness let alone any specialist knowledge. But more importantly, she clearly wasn’t interested in listening to my attempts to explain it. Thankfully, by the time I got to see Atos, I was well on the road to recovery. I also had a very understanding employer who managed my return to work superbly. Otherwise, this whole process would have been a nightmare and would possibly have led to a relapse through a hurried return to work.

  9. nurseagainstatos November 30, 2011 at 1:10 am #

    Can anyone help here? I have got the part of the contract between Atos and the DWP that talks about staffing levels. Atos have told me verbally that they have been told that they can only employ Adult/general nurses to do mental health assessments, but according to this part of the contract, it just says registered nurse. So can anyone tell me if there is any reason why nurses cannot be recruited from each part of the register to do the assessment that they are best qualified to do ?
    2.1.11 The Welfare Reform Act 2007, allows HCPs to conduct medical examinations to assist DWP Decision Makers determine benefit entitlement. This legislation clearly defines “health care professional” to mean —
    (a) a registered medical practitioner,
    (b) a registered nurse,
    (c) an occupational therapist or physiotherapist registered with a regulatory body established by an Order in Council under section 60 of the Health Care Act 1999, or
    (d) a member of such other profession, regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002, prescribed by the Secretary of State in accordance with powers under section 39(1) of the Social Security Act 1998.”

  10. Margaret McCartney
    margaretmccartney November 30, 2011 at 8:33 pm #

    All I can say is that at the recruitment evening I went to, they said that the only thing nurses couldn’t do were ‘neurological’ problems. They couldn’t tell me why. I have asked Atos this, and they have declined to tell me. I am presuming they don’t want psychiatric nurses who could ‘only’ deal with psychiatric problems and not mixed problems or physical health problems and be, presumably, less efficient for them. But I don’t know. The lack of transparency is dreadful.

  11. Mo Stewart December 9, 2011 at 2:10 am #

    I’ve received a letter from the DWP Chief Medical Officer claiming that the new PIP assessments will be ‘put out to tender’ to private sources for assessment, claims that the company has not yet been chosen and claims that it won’t necessarily be Atos who do the PIP assessments…. Time will tell. However, given the amount of facilities Atos already have, and they are at full stretch, with the fact that they knowingly overbook all appointments by 20% in case some people don’t turn up, let’s hope that Atos are not appointed and let’s hope that the DWP get around to actually auditing the Atos contract – something they have never done according to the DWP, despite claims in the House of Commons.