Personal View: Patients, doctors, and sickness benefit
Authors: Björn Nilsson, Iona Heath
Journal: BMJ (2003)

In the United Kingdom more than 2.7 million people of working age—about 7.5% of the working age population—are now claiming incapacity benefits. The number has more than trebled since the 1970s. Similar disturbing trends have been reported across Europe, at a time when all the other indicators are that general health is improving. Each person now claiming incapacity benefit began by asking their doctor for a sickness certificate.

As businesses increasingly prioritise corporate profit above any other considerations, the population becomes polarised between those who have no work and those who have too much. The growing number of people who are either unemployed ever increasing demands and expectation. Leaner and fitter organisations have cut staff to the minimum, increasing the stress on those who remain. The resulting feeling of loss of control has a negative effect on health. As soon as one person feels no longer able to cope and takes sick leave, the pressure on the remaining staff is ratcheted up yet again.


General practitioners feel themselves to be the functionaries of an oppressive economic system


At its best, work is a source of fulfilment, dignity, social contact, achievement, usefulness, and economic self sufficiency; at its worst, a source of anxiety, sleeplessness, fear, humiliation, and despair. Almost no one wants to be excluded from the opportunities offered by work, but many people are defeated by its demands. Much has been written about the increasing absence due to illness, but the voices of those directly affected are seldom heard. Their stories are heard in the general practice consulting room, and each story is different and requires a different solution. The predicament of someone who feels forced out of work by an uncontrollable workload is different from that of the teacher who feels threatened by violent pupils and different again from that of the person with no educational achievement and who may come from a family entering its third generation without work.

It is easy for beleaguered policy makers to regard claimants of incapacity benefit as manipulative and general practitioners as failing in their role as gatekeepers to the welfare benefit system. Such a view is unhelpful, as patients and general practitioners are well aware of their predicament.

The discipline of general practice is founded in the long term relationship between doctor and patient, which nurtures mutual respect and trust. Patients can trust doctors only if they feel heard and understood, and this can happen only if doctors, in turn, trust patients to give a truthful account. If general practitioners feel themselves to be under pressure and begin to regard every request for a sick certificate as suspicious, trust is very rapidly undermined and, once gone, is difficult to rebuild. Increasingly general practitioners feel themselves to be the functionaries of an oppressive economic system and obliged to control access to the benefit system, a position that conflicts with a responsibility to act as the individual patient's advocate.

Undoubtedly, many people currently claiming incapacity benefit have lives that could be better, in many ways, if they could return to work. People who are excluded from work have worse health and a lower expectation of life. General practitioners understand this and yet are acutely conscious of the huge barriers that can prevent return to work. Experienced doctors are also aware of a critical point of irreversibility after a period of absence from work: the longer one puts off trying again, the less likely is one ever to manage it. In Britain the average length of absence from work among people who have been on incapacity benefits for 12 months or more is eight years.

The solution lies not in cajoling claimants or their general practitioners but in rediscovering, even requiring, a socially inclusive solidarity in the workplace. Many labour organisations seem to have lost their way in the later years of the 20th century and now devote more resources to providing counselling for individual workers than in improving terms and conditions for everyone. The number of people taking sick leave will fall only if doctors can refer workers—as soon as absence from work looks likely to become prolonged—to non-stigmatising employment rehabilitation that is genuinely supportive.

People trying to return to work need opportunities for part time work in sheltered environments, and they need to be able to exert a degree of control over their work and to be paid more than they would get on benefit. All businesses and workplaces should be supported and even subsidised to provide environments that accommodate a range of capabilities but within which everyone is allowed the dignity of work. The obligations of economic profit and social solidarity pull in different directions, and the conflict is played out between patient and doctor in the consultation over sick certification. However, more can be done to resolve the problem outside the consulting room than inside it.