Sick leave certification in primary care: Primary care physician experience and attitudes in Västra Götaland region, Sweden

Problem

The cost for sick-leave benefits is increasingly seen as a problem in Sweden. To reduce the cost, a number of supporting structures have been introduced including 1“Guidelines for Sick Leave”, i.e. web-based recommendations from the National Board of Health and Welfare, 2local educational activities for physicians, 3coordination at health care centres to facilitate patient rehabilitation, and 4“the rehabilitation chain” which sets time limits for the sick leave insurance. In parallel, free choice of caregiver in primary care for the patient has been introduced and the number of registered patients forms the basis for the reimbursement to health care centres. Previous studies have shown that primary care physicians consider sick leave certification as troublesome. To gain better understanding of this issue, we performed a study in primary health care in Västra Götaland.

Approach

A qualitative research approach was applied, using six focus groups with 2-8 physicians in each group, selected by purposive sampling (GP, GP trainee, interns and locums). The interviews were mostly preformed at the health care centres. A GP/researcher acted as moderator and a research secretary observed and transcribed the interviews verbatim.

Qualitative content analysis is used, looking for both manifest and latent content. The first author (a GP/PhD student) carries out the first analysis which is discussed with the second author (a GP/researcher) and the supervisor (a dentist /researcher with good knowledge and experience of qualitative methods) to arrive at an overall agreement on the interpretation and achieve trustworthiness (credibility, dependability and transferability).

Findings

Preliminary results from the ongoing analysis are presented below.

Sick leave certifications were generally seen as a problem, and some physicians even regarded the task as a work environment hazard. The physicians often felt alone in the work with and pointed out a lack of specific guidelines for the management of sick leave and rehabilitation, although the supporting structures described above seemed to be of some help.

Rehabilitation meetings with the patient, the social insurance officer, the employer and the physician were considered to improve the collaboration and the rehabilitation of the patient.

While the free choice of health care centre could be positive for the patients, a risk of discontinuation in the care was discussed. The physicians described that some patients were “shopping around” for sick leave certificates. In primary care, sick leave certification was felt to consume resource at the expense of patients who may have a greater medical need. A metaphor that was used was that sick leaves were the “heart attacks of primary care”.

Consequences

In this study, Swedish GPs considered sick leave certifications a large and sometimes troublesome part of their workload. They often were left alone with difficult decisions. Supporting systems should be improved.