Abstract

Background Evidence suggests that overall the benefits of work are greater than the harmful effects of long-term unemployment and prolonged sickness absence. General practitioners (GPs) often feel that work and health-related issues extend beyond their role. There is a paucity of research that focuses on GPs’ attitudes to the management of long-term worklessness.

Aims To explore GPs’ perceptions of the management of individuals in receipt of long-term incapacity benefits and their attitudes to UK government funded return to work programmes such as the Want2Work scheme in Wales.

Methods A qualitative study set in South Wales. Focus groups were conducted with GPs and explored the role of primary care and the challenges that GPs face when managing long-term worklessness and how the Want2Work programme might benefit GP practice. Data were analysed using the framework method of analysis.

Results The main themes that emerged from the GP focus groups were role boundaries, responsibilities, negotiation and knowledge. A key finding was that many of the participants felt that their role in managing long-term worklessness was limited to providing support and management of health-related issues only. The perceived risk to their own personal safety in addressing these issues with some patients also impacted on GPs’ decision making

Conclusions There seems to be a clear divide between managing patients’ health concerns and their work-related activities. Some GPs recognized that patients became ‘lost’ in their system once receiving long-term benefits.

Introduction

There is now evidence to support that work is generally good for physical and mental health and well-being. Evidence strongly suggests that overall the benefits of work are greater than the harmful effects of long-term unemployment and prolonged sickness absence [1]. For people who have been on prolonged sickness absence for 23 months, there is a 90% chance that they will not return to any form of work in the foreseeable future [2].

Dame Carol Black's report (2008) on the Health of Britain's working age population raised key issues about work and health that were relevant to general practice [3]. The report focused on the need for improved training for general practitioners (GPs) in the area of health and work; review of the sickness certification process and the need to develop case-managed multidisciplinary services that provide GPs with easy access to advice and support about rehabilitation and return to work.

GPs in the UK and elsewhere often feel that managing work and health issues per se goes beyond their role [4–6]. GPs in The Netherlands do not play a role in sickness certification process. A study that investigated Dutch GPs’ management of patients who had been absent from work for over 12 weeks showed that many failed to discuss work issues with their patients. Furthermore, they rarely applied work-related interventions to their patient management [7]. The reasons behind this failure by GPs to address long-term worklessness remain unclear.

Research has identified four main factors that influence GPs in their attitude to the management of return to work issues: the doctor–patient relationship, patient advocacy, pressure on consultation time and limited occupational health expertise [5,8,9]. How these factors specifically relate to the management of long-term worklessness is not yet understood.

Since 2003, the UK government has been piloting an initiative aimed at improving opportunities for those people in early receipt of state incapacity benefits at risk of long-term worklessness and benefit dependency. The Pathways to Work (PTW) programme provides a single gateway for financial, employment and health support for individuals claiming incapacity benefits [10]. This programme shows great promise for supporting people back into and maintaining them in employment [11,12]. Evaluation of the outcomes of the programme highlighted an increased self-confidence and motivation to return to work in programme participants [13]. The PTW programme is now being rolled out across the UK. However, reports suggest that GPs rarely engage with these services directly [14].

In Wales, a further scheme known as Want2Work has been piloted and targets communities in South Wales with high levels of economic inactivity. The Want2Work scheme is based on the PTW model but specifically provides support for those individuals who have been out of work for >1 year. Analysis of the referral data to this scheme indicates that GPs rarely access it directly.

This study took place in 2007 and was funded by Jobcentre Plus. The aim was to investigate why GPs failed to engage with rehabilitation services and schemes such as PTW and Want2Work and informed by this work build a web-based intervention to support engagement and training about the management of long-term worklessness in primary care. The programme would complement an educational programme developed at Cardiff University about the everyday consultation about work and health called ‘Sick Note or Bust’ [4].

This paper describes the first stage of the project that investigated GPs’ attitudes to the management of long-term worklessness. This qualitative study used focus groups in South Wales to specifically explore GPs’ perceptions of the management of individuals in receipt of long-term incapacity benefits and their attitudes to UK government funded return to work programmes such as the Want2Work and PTW schemes.

Methods

The project was time limited to 1 year. GPs were recruited from two defined target areas in Cardiff and Neath Port Talbot where the Want2Work scheme operated. Recruitment was conducted via letters sent out by the Want2Work project manager to GP practices. Individual practices that expressed an interest in the study were contacted by the research team to discuss the details of the study further. Focus groups took place at the premises of participating practices and lasted ∼1 h. Consent was obtained from each GP partner at the start of the focus group. One focus group was carried out with academic GPs from the Department of Primary Care and Public Health, Cardiff University. This final focus group was conducted to provide data from a wider GP audience who practised outside the Want2Work scheme area. Four of the groups were facilitated by NM and KW and one by DC. A topic guide was constructed based on an initial literature review and discussion with experts (see Figure 1).

Figure 1.

GP focus group topic guide.

Figure 1.

GP focus group topic guide.

The focus groups explored the role of primary care in managing long-term worklessness, the challenges that GPs face when managing long-term worklessness and how programmes such as the Want2Work scheme might benefit the management of patients who are out of work long term. The focus groups were audio-recorded and transcribed verbatim. The framework method [15] of analysis was employed. This approach is useful for applied or policy-relevant qualitative research where there are short timescales and preset aims and objectives [16]. The transcripts were read by two of the researchers (NM and KW) to initially identify the broad themes. This was guided by the topic guide. The themes were discussed and refined with senior researchers (MR and DC) and a coding schedule agreed. This schedule was then applied to all transcripts. Analysis was iterative, initially broad themes were identified followed by subthemes. Transcripts were continually reassessed and re-interpreted until themes and subthemes were finally agreed by all the researchers.

Ethical approval for this study was granted by the North Somerset and South Bristol Research Ethics Committee.

Results

Five focus groups were conducted and analysed. One focus group was conducted with each of the participating four practices. The fifth focus group was conducted with six academic GPs from the Department of Primary Care and Public Health, Cardiff University.

Sixteen GPs took part in the four practice focus groups along with two practice nurses, a practice manager and a medical student. Of these, 9 were female and 11 male. The GPs that took part had been qualified for a mean of 19.9 years (range 7–33 years). Two of the practices were in urban areas, one rural and one semi-rural. Two of the practices were training practices. Six GPs took part in the academic focus group, five female and one male.

The main themes that emerged from the GP focus groups were role boundaries, responsibilities, negotiation and knowledge. There was consensus among participants that the management of long-term worklessness was not part of a GP's role. Participants described clearly their feelings about the boundaries that existed between managing their patients’ health and managing long-term worklessness. They described how once an individual was in receipt of long-term benefits the role of the GP was to solely manage their patients’ health-related issues. GPs did not feel that discussion about work-related issues with their patients was of high importance nor part of their role and as a consequence did not routinely enquire about work or attitudes to returning to employment. Some participants believed that referral to rehabilitation services was outside of their remit. Some, however, felt their role did include providing advice about rehabilitation support services. Although they were cautious in referring people to services that they saw as transient or only being piloted as this ‘wouldn't be in the patient's best interest’ long term and would affect the GP–patient relationship in the future. This was reflected in discussions about patient management (see Box 1).

Box 1.
Role boundaries

‘We don't see that [referring patients to a return to work scheme] as our primary role … our role is health … and primary health and prevention’ (GP2, male)

‘Strange thing is we don't see them because … once they've been … got so many weeks or whatever it is they don't have a certificate anymore … so they don't need to come and see us’ (GP1, male)

‘Want2Work is an excellent idea and obviously my role isn't that unless they have an illness for which they need medical help … but if it's just purely because they're out of work I don't personally think that's a GP role’ (GP5, male)

‘If it was a service you thought “I'm not happy about that service being in this surgery cos I'm not going to trust it” you wouldn't refer to it probably either, I'm sure you wouldn't.’ (GP12, female)

There was strong feeling among some participants that discussing return to work once a patient was on long-term benefits lay outside of GPs’ contractual responsibilities. Once patients were in receipt of long-term state benefits, they saw the responsibility for instigating a discussion about return to work lay with the benefit department. One GP described how if a patient did not need a certificate then ‘I don't particularly instigate any discussion about work … personally …’. Another participant described this clearly in saying it was ‘not really my responsibility any more because I'm not the person who's … saying they're incapable of work’. Others described how they were aware of the physical and psychological effects of long-term worklessness and that they had a responsibility to address these issues in the consultation but felt limited in what they could achieve. Participants described clearly the tension that at times existed when their role in supporting their patients became blurred with the contractual responsibilities. This in turn impacted on doctors’ ability to negotiate effectively. There was a clear agreement among participants that negotiation with patients about a return to employment was not easy. A number of participants described feeling uncomfortable about raising the subject of work and believed that patients often did not want to discuss employment with their doctors. They described how patient expectations impacted on negotiation. Patients expected GPs to be their ally and to support their claims for state benefits without challenging them. One GP expressed this as just being a ‘vehicle for the benefit system’. Some quotes are illustrated in Box 2.

Box 2.
Negotiation

‘you've obviously got to be quite empathetic to how they're feeling but if you want to broach the situation of perhaps returning to work and how that's going to be achieved it's quite a difficult consultation’ (GP7, female)

‘I think we would all say we've got more experience of somebody coming back and saying “I need your back-up to stay on the sick” rather than folk coming up and saying “I really would like to get to work”’ (GP8, female)

‘I'm afraid an awful lot of my impression is they don't want to be seen … you know they've got their benefit and that's what they're after’ (GP9, male)

‘If they come to see you it's not with the aim of getting better … not a bit … it's “I've got my review coming up tell ’em how bad I am doc” you know’ (GP10, male)

This tension around negotiation often left GPs feeling frustrated and at times angry that they recognized in turn could lead to conflict. Participants described how GPs at times had to weigh up negotiation with their own personal safety. They recognized that they often shied away from confronting patients about their ability to work as they put their own personal safety first. This is illustrated clearly in the quotes in Box 3.

Box 3.
Conflict and personal safety

‘You don't want bricks thrown through your window and/or your tyres slashed on your car’ (GP3, male)

‘It's just not going to happen … I value my front teeth too much’ (GP4, male)

‘It's easier for me to give him a sick note than argue with him or in the middle of a packed surgery’ (GP3, male)

Participants felt uneasy about trying to separate the health aspects of returning to work and the financial implications that this might bring to patients and also impacted on their negotiation (see Box 4).

Box 4.
Financial incentives

‘I mean theoretically all these initiatives are good but you've got to motivate your patients first before you actually do that sort of thing (refer for rehabilitation support) Cos they're all saying they're better off on the sick and that's it!’ (GP8, female)

Participants, however, recognized that some of the difficulties they experienced in negotiating related to their lack of knowledge about work and health and the state benefit systems. There was clear agreement that GPs lacked training about the health effects of worklessness. There was also strong feeling that it was hard for GPs to keep up to date with new government initiatives. Many participants recognized that they often lacked enough knowledge about the different benefits available for patients and how to access them. There was clear agreement among participants that understanding how the varying government systems worked and patients’ eligibility for the different types of benefits and schemes impacted on patient management (see Box 5).

Box 5.
Knowledge and keeping up to date

‘We’re not trained in occupational therapy …. How can you say whether this patient is fit to work … you don’t even know aspects of their job … so it’s a tough call’ (GP5, male)

‘There’s always new government initiatives and to try and … we’re trying to keep up with medical stuff and trying to keep up with sort of social stuff as well is incredibly hard’ (GP6, female)

‘I feel I don’t understand the system, I mean it’s so complicated … so when people are saying to you “well financially I’m gonna be worse off” I can’t say “well that’s not true” because I just don’t know it well enough to know’ (GP6, female)

There was strong feeling from some participants that at times not having enough knowledge about local government agencies and poor communication between such agencies and primary care led to time wasting. One participant voiced his frustration about trying to refer patients, ‘I've sent quite a few of them and they say “I'm very sorry you live on the wrong side of the road”’.

Discussion

A key finding of this study was that many of the participants felt that their role was limited to providing support and management of health-related issues only and the management of long-term worklessness lay outside of the GP role. Some GPs commented that patients on long-term benefits often became ‘lost’ within their practice systems and that rehabilitation with these patients was rarely discussed. This finding is closely linked to GPs’ perceptions of their responsibilities about health and work. Once a patient has been on ill-health state benefits for 28 weeks, the GP is no longer required to provide regular sickness certification. The perception from participants was that this implied they no longer had a responsibility to consider work-related issues. This may in part explain the finding that GPs often fail to address long-term worklessness in their consultations [7]. This is an important finding in light of the recognized impact of worklessness on health and well-being.

We identified several factors that explain why GPs find managing long-term worklessness so challenging. These broad themes are not only specific to the management of those on long-term ill-health state benefits but apply also to the much broader research on sickness certification management [5,17,18]. However, the focus in this study was to understand GPs’ attitudes and expectations specifically to the management of long-term worklessness. This work illustrates some of the complexities GPs face in addressing these issues. It illustrates how a lack of knowledge about the specific health impact of long-term worklessness alongside the perceived difficulties for GPs in understanding and accessing the UK ill-health benefits system impacts on their confidence to negotiate effectively with their patients around these issues. An important finding is that GPs clearly described the perceived risk to their own personal safety in addressing these issues with some patients. This in turn may impact on GPs’ decision making and low referral rate to rehabilitation services.

The study had a number of potential limitations. The sample consisted of GPs recruited from two specific areas across South Wales with high levels of economic inactivity. This raises the question whether this was a representative sample. However, the data collected showed that the attitudes and beliefs of the participants with respect to sickness certification and the management of short-term worklessness were comparable to other studies [5,9,17,19,20]. A further limitation relates to the generalizability of the data. There was no financial incentive for GPs to take part in the study and recruitment was limited. The final group therefore can be assumed to have had a specific interest in this subject. The purpose of the study was, however, not to produce a representative sample but to try to gain an understanding of some of the perspectives and issues that arise in the management of long-term worklessness in primary care. These in turn will inform further work in this area. The study was also time limited due to contractual agreements with the funding body. It is recognized that a more detailed understanding of the emergent themes could have been undertaken if the study had been extended. The study used the framework analysis as described by Ritchie and Spencer [15]; however, the authors recognize that there are other approaches to using the framework method of analysis [21].

Studies to date have explored sickness certification in primary care and have provided greater insight into GP perceptions of their role in the management of short-term sickness absences. Hussey et al. [5] illustrated how GPs manage the certification process to overcome some of challenges they encounter. Logfren et al. [22] looked at the rate of problems GPs encounter in managing certification issues. Thorley et al. [23] using the THOR—GP (a national network of GPs interested in occupational health and reporting cases of work-related ill-health) reviewed the trends in work-related ill-health reported by this group. Reiso et al. [24] investigated the accuracy of GPs’ return to work predictions for their patients. They noted that GP accuracy was much higher for short-term than long-term absences. Sheils et al. [20] investigated patient factors that influenced the duration of sickness absence and transition to state incapacity benefits. Some studies explored the nature of the sickness consultation [19,25] itself and recognized both communication and system issues impacted on GPs’ attitudes to work and health.

This study begins to explore specifically GPs’ attitudes to the management of long-term worklessness, which is an area currently under researched. It provides some insight into GPs’ perceptions of their role and attitudes to their contractual and ethical responsibilities about the management of long-term worklessness and provides some insight into why GPs do not engage with rehabilitation services such as PTW and Want2Work.

Failure to return to work is often due to wider biopsychosocial factors that impact on the individual rather than their medical condition itself [26]. Therefore, to enable individuals to return to work and so reduce the risks associated with long-term worklessness, there is a need for these wider factors to be addressed. This study illustrates that the communication between GPs and government and voluntary schemes to support individuals may not be as effective as was hoped. This is an important area that requires further consideration, especially in the light of the government response to the Carol Black report [3] and the future development of fit for work services.

This study also highlights the need to address the effects of long-term worklessness as part of work and health issues in GP training. This study has informed the development of a new online training package for GPs that is being developed in collaboration with the Royal College of General Practitioners, the Society of Occupational Medicine and the Faculty of Occupational Medicine. It has also informed the content of the new GP National Programme for Work and Health. Evaluation of the pilot programme has highlighted that prior to the training, GPs felt they lacked both knowledge and confidence in managing these issues. Outcomes of the pilot programme included an increase in GPs’ perception of the importance of addressing work and health issues in the consultation coupled with an increase in their confidence in conducting these discussions with their patients [27].

Finally, GPs stated that keeping up to date with changes in government systems both locally and centrally impacted on their decision making. GPs seem unaware of what schemes are available for them to refer patients to. Therefore, further consideration needs to be given as to how to inform GPs about changes in government systems, improve their feelings of ownership over the processes that impact on their patients and increase their confidence in referring to newly developed schemes.

Key points

  • General practitioners felt their role was to provide support and management of health-related issues only and the management of long-term worklessness lay outside of their role.

  • Patients on long-term benefits often became ‘lost’ within GP practice systems and that rehabilitation with these patients was rarely discussed.

Funding

Job Centre Plus (DWP/010/04167).

Conflicts of interest

None declared.

The research conducted as described in this paper led to the development of an online educational programme for GPs also funded by Job centre Plus and is available free to GPs via www.healthyworkingwales.com.

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