Sick notes and ‘Culture’

Ben Hoban is a GP in Exeter.

It’s difficult to know what to make of the Prime Minister’s recent comments about “sick-note culture.”¹ On the face of it, there is nothing unreasonable about reviewing the current system of sick certification by GPs, which can be a helpful part of patient care, but often represents just one more administrative burden in an already busy day. Even the fact that such a review is driven by financial pressures need not be a bad thing: the more people enabled to return to work and pay income tax, the more money there is to pay out in benefits to those who depend on them. What stands out, however, is the reference to culture, implying not just that the system needs to be changed, but that it is somehow being subverted by a set of questionable values and norms. It is in fact well established that ideas and behaviours related to our health are universally influenced by cultural factors.² I would like to suggest three such factors that may be relevant to the observed increase in sick certification.

First, we have experienced a definite change in our attitude to ill health as a society, from carrying on regardless – now referred to as presenteeism – to stewarding our health as a precious resource. Since the Covid-19 pandemic, we think more readily of looking after others by isolating ourselves when ill, and looking after the health service by not risking illness at all. Even well before this, we were promoting vigilance for signs of meningitis, strokes, sepsis and cancer in terms reminiscent of terrorism awareness campaigns. Unattended luggage? See it, say it, sorted! Changes in a mole? Get it checked! Corresponding efforts to raise the profile of psychological problems are especially relevant, given the disproportionate rise in sick certification for mental ill health in young adults.^3,4 We have encouraged people for years to be more open to the possibility of illness, and are now left with the unintended consequence that they have taken the message to heart.

Secondly, our focus in relation to ill health has shifted from acute problems to long-term physical and psychological conditions, some of which would once either have been considered normal, or swept under the carpet.⁵ Arthur Frank identifies three main narratives in relation to illness: Restitution, or simply getting better; Quest, or personal growth through adversity; and Chaos, in which things don’t make sense, they simply happen as they will.⁶ Any ongoing condition necessarily excludes the first, and any attempt to make sense of it naturally avoids the last. The only positive story left to the chronically unwell then is to accept what they must and look for some good in it. To tell someone in this position that they are either not sick enough to qualify for benefits, or not trying hard enough to get better, rather misses the point. It also raises the question of how we decide who can occupy the sick role, which brings us to our third cultural change.

Talcott Parsons originally described the sick role as one of several ways in which society recognises deviance from accepted norms of behaviour, other examples including criminality and insanity.⁷ According to this view, if you can’t fit in, there must be something wrong with you. Our current ideas of normality are more descriptive than prescriptive, and we view diversity as something positive rather than an anomaly needing to be legitimised. As a result, we have come to see ourselves as defined less by the things we have in common, and more by the things that make us distinctive. In this context, poor health easily becomes one of the facets of a person’s identity, and attempts to challenge this are likely to come over as personally invalidating.

The difficulty with this position is that it obliges the system to pay benefits to someone purely on the basis of how they see themselves. As doctors, we try to take what patients tell us at face value and be supportive where we can; we have to choose our battles carefully, and we have no way, ultimately, of verifying someone’s story. Rishi Sunak may therefore be right that we are not the best people to question someone’s reported inability to work. The idea that this can be done fairly and objectively by someone else, however, seems dubious. In order to be fit for work, a person must be capable of more than simply carrying out in isolation the tasks required by their role: they must be able to do so repeatedly, to a consistent standard, and in a way that represents a reasonable balance of benefits and burdens to them. If working in toxic conditions for a pittance leaves you too exhausted or stressed to do anything else, you are not fit to work by any reasonable standard, or by any standard at all for long, even if you can turn a handle or click a mouse when asked.

Where does this leave us? The idea that we can consider ill health without taking into account our wider cultural context is a non-starter. We might rather consider to what extent we have contributed to the current culture by setting out to change the way people relate to their health, and to healthcare: in lighting a candle of increased illness awareness, we have also cast a shadow of increased illness behaviour. There are unlikely to be any simple solutions, but a new sick-certification service will need to demonstrate that it can cut costs without being punitive and arbitrary, or increasing demand for appointments as patients seek help in appealing decisions made against them.

Deputy Editor’s note: Join the discussion and also see – https://bjgplife.com/what-drives-the-sick-note-culture-in-the-uk/, https://bjgplife.com/could-new-changes-to-the-fit-note-be-an-opportunity-for-primary-care/ and https://bjgplife.com/why-gps-must-not-lose-their-role-in-supporting-people-back-to-work/

References

1. Press release: PM to overhaul benefits system and tackle Britain’s “sick note culture” in welfare reform speech – GOV.UK (www.gov.uk) [accessed 8/5/24]
2. Cecil Helman, Culture, Illness and Health 5th ed, CRC Press, 2007
3. Arie S. Simon Wessely: “Every time we have a mental health awareness week my spirits sink” BMJ 2017; 358 :j4305 doi:10.1136/bmj.j4305
4. HM Government, 2011, No health without mental health: a cross-governmental mental health outcomes strategy for people of all ages, dh_124058.pdf (publishing.service.gov.uk) [accessed 8/5/24]
5. The Heath Foundation, 2023 , What we know about the UK’s working-age health challenge, https://www.health.org.uk/publications/long-reads/what-we-know-about-the-uk-s-working-age-health-challenge
6. Arthur Frank, The Wounded Storyteller: Body, Illness and Ethics, University of Chicago Press, 1997
7. Talcott Parsons, The Social System, Glencoe, 1951

Featured photo by Viktor Forgacs™️ on Unsplash