Doctors Must Be Doctors

by Dr. Nileema Conlon Vaswani in

With long hours of work and increasing responsibility, it will be no surprise if Britain's doctors write themselves a few "sick notes" just to escape from what might seem to be an increasingly unreasonable workload. I do not mean that they have an unreasonable workload because they have too many patients to see. The problem that faces them and our society is that the Government expects their role to assume a whole new meaning.

This week, the Government has suggested that the number of people on incapacity benefit needs to be lowered and wants GPs to help them achieve this goal. It has asked that GPs write "well notes" rather than "sick notes" so that they can explain what patients are capable of doing rather than what they are unable to do. Part of this process entails suggesting ways in which people can help themselves get better so as to return to work.

GPs are, of course, meant to suggest ways of curing or at least managing illnesses but does their duty really extend beyond that? Their duties are to their patients and not to their patients' employers. While they may be better placed than anyone else to gauge how sick an individual patient is, that does not qualify them to make an assessment as to whether or not the individual is fit to work. With the exception of obvious cases where an illness is so severe that the patient cannot do anything, regardless of the type of employment in question, most cases are difficult to assess in terms of fitness to work.

Fitness to work is contingent on a host of factors of which the health of the patient is only one. These factors include hours of work, timings of work, shift patterns, the nature of the work, the environment and one's commute. How well or ill someone is for work depends on the impact that these factors are likely to have on their illness. For example, an individual suffering from a certain medical condition might be able undertake certain tasks if working from home but not from an external workplace that entails a long commute, a crowded environment, etc.

For doctors to make genuine and accurate assessments about patients' fitness to work, they would need information on all these external factors. This would be a long and time-consuming process and, in its own way, expensive. Spending more time with each patient in order to make absolutely sure that the patient is not only ill but also too ill to work will invariably have an impact on waiting times for other patients. This means that those patients who have taken an hour or two off work to visit their GPs might end up waiting to see their GPs for much longer, thereby losing more work time. A system where doctors have to assess fitness to work will only be self-defeating.

But the Government wants even more than that. It wants doctors to issue "well notes" that describe what the patient can do. It is not clear how this would work. Clearly, there are a lot of activities that a person can do that may not be relevant to one's ability to work. If at all these notes are likely to be effective they would need considerable detail and relevance to the job in question. And to include detail, the doctor needs access to information on external factors that, as has already been discussed, is problematic.

Patients who suffer from mental health problems will be most affected by these new measures. If the impact of physical illness on one's ability to work is difficult to determine because of the external factors involved, then assessments of an individuals ability to cope if he suffers from a mental health problem will be that much harder to pinpoint. On a certain day, an individual may be able to do his job quite easily but on another day he might struggle to do so. If GPs decide that it is best to issue a "sick note" for a few weeks until patients with mental health problems cope with their illnesses, then their judgement ought to be respected. It is not fair on them or their patients to ask that they encourage them to return to work because doing so may not be in theirs or their employers' interests.

Although the changes being proposed are intended to apply to those on incapacity benefit, in the interests of consistency and fairness, the system will have to apply to everyone. If doctors are issuing "sick notes" that are more detailed or thorough by assessing fitness to work, or "well notes" that indicate what the patient is able to do, the same process of assessment will have to apply to anyone who is sick and requires a note. Assessments of illness have to be carried out consistently by doctors even if the information obtained from these assessments has different uses. Regardless of whether doctors notes are used to take one day off work, six months off work or, via a "well note", even do limited work, the assessments ought to be the same.

The Government's real concern is those who are unjustifiably on incapacity benefits and it is right to identify a problem here. Its proposed solution, however, is less than feasible. For the sake of ensuring that a few people who "play" the system are caught, it is placing an unnecessary burden on the health service. GPs cannot work any longer than they already do and patients are unlikely to want to wait longer to see their doctors. Giving GPs this additional responsibility will only stretch a health service that is already struggling to cope with the needs of patients and result in many genuinely sick people who are eager to return to work spending hours in the waiting area of their doctors' surgeries.