Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan
I wrote previously here on BJGP Life about spiralling fuel costs and the increasing risk of fuel poverty alongside a cost of living crisis and rising inflation. In a ‘knight’s move’ to mitigate the increasing costs of living for the most vulnerable, the Treasury has recently put forward proposals suggesting that GPs should assess the financial health of their patients and recommend financial support to those in most need. The RCGP Council Chair, Martin Marshall, immediately disputed the plans, stating that ‘GPs and other members of our team are not qualified to assess whether people should or should not receive additional financial support to help them cope with rising cost of living.’1 This strategy to make GPs responsible for societal assessments, however, reflects the ways in which GPs act as administrators for the state, sometimes rightly, and sometimes wrongly.
What are the responsibilities of a GP? Our primary duty is to our patients but increasingly, GPs have assumed wider roles and responsibilities within society. These responsibilities include medical reports to appeal refused welfare benefit payments, fit-to-fly letters, or sending information to police for firearms licensing. But what is within the scope of our professional competencies?
Our primary duty is to our patients but increasingly, GPs have assumed wider roles and responsibilities within society.
Fit notes are one example of how assessments (within our scope) and judgements (potentially out of scope) might become conflated and muddled. Fit notes are a form of medical evidence that have serious implications not only in terms of access to statutory sick pay and health-related benefits, but in terms of how a work schedule or environment might be adjusted. GPs are asked to assess and provide factual information about a person’s illness, which seems reasonable, but we are asked often to veer into speculation and judgements.2 Some GPs feel that aspects of the fit note, such as recommending amended duties and workplace adaptations, fall outside their area of expertise.3 This feeling isn’t surprising, as giving specific occupational health advice to employers is not typically part of a GP’s expertise or role.
Assessments can be impacted by, and can impact on the doctor-patient relationship. Research has shown that some GPs completing fit notes emphasise their role as a patient advocate, accepting what the patient says at face value. However, some GPs were reluctant to anger or upset patients if they held a ‘conflicting view’, especially relating to long-term illnesses or non-visible conditions such as chronic pain.4 As Wainwright et al point from their research, appropriate use of the sick note is a potential source of tension in the doctor-patient relationship and can lead to conflict.5 Practice is not standardised and there is wide variation in terms of fit note completion between different practices and patient -level factors such as gender and social deprivation can impact on how such assessments are completed.6
…GPs feel undertrained and unqualified to conduct assessments, that there is wide variation in practice, and that some populations receive different outcomes than others.
The research around assessments such as fit notes shows that practice is not standardised, GPs feel undertrained and unqualified to conduct assessments, that there is wide variation in practice, and that some populations receive different outcomes than others. Where would all this leave GPs if we were required to assess whether our patients qualify for financial support? Our primary duty, I repeat, is to our patients. Our limits need to be clear when considering whether we are making a medical assessment or a societal judgement. Is it within our professional competencies to assess for financial need? And in terms of a judgement, if we come back to fit notes, guidance from the BMA suggests that GPs ‘should not speculate but should provide only factual information and should not certify something they are unable to verify.’2 If we apply the same framework to our patient’s financial welfare, GPs are simply not placed to have the right factual information to assess, or judge our patients’ financial need. And in our role as patient advocates, who are we going to say no to? We need to proceed with caution. Action needs to be taken to minimise the increasing costs of living on the most vulnerable in society, but the government shifting responsibility to GPs seems like a deeply poisoned chalice.
References
1. Action to tackle cost of living crisis ‘cannot fall to GPs to facilitate’: RCGP Press Office; 21 August 2022 [Available from: https://www.rcgp.org.uk/News/Cost-of-living-crisis.
2. Issuing fit notes: British Medical Association; 2020 [Available from: https://www.bma.org.uk/advice-and-support/gp-practices/gp-service-provision/issuing-fit-notes.
3. Fylan BF, F.; Caveney, L. An evaluation of the Statement of FItness for Work: qualitative research with General Practitioners. Sheffield; 2011. Contract No.: Reearch Report No 780.
4. Welsh VK, Mallen CD, Wynne-Jones G, Jinks C. Exploration of GPs’ views and use of the fit note: a qualitative study in primary care. Br J Gen Pract. 2012;62(598):e363-70.
5. Wainwright E, Wainwright D, Keogh E, Eccleston C. Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study. Br J Gen Pract. 2011;61(593):e794-800.
6. Shiels C, Gabbay M, Hillage J. Factors associated with prevalence and types of ‘may be fit’ advice on fit notes: a cross-sectional primary care analysis. Br J Gen Pract. 2014;64(620):e137-43.
Featured photo by Birmingham Museums Trust on Unsplash
