In 2007 new guidelines were introduced for sickness certification in both Norway and Sweden. However, the amount of sickness certification has not changed significantly in either of the two countries following this. Discussions among doctors and the dialogue between doctor and patient appear to be more important for the decision to issue a doctor’s certificate or not than the guidelines.
Studies conducted in Sweden in 1995 (1) and in England in 2002, evaluated in 2008 (2), showed that the effect of the then prevailing guidelines on doctor’s certificates was short-lived and that the guidelines had no impact on long-term sickness absence.
New guidelines for doctor’s certificates were introduced in 2007 in both Norway and Sweden (3, 4). The official certification form in Norway was changed from 2008, making it simpler for doctors to give advice about the interaction between patient and employer (5). Sweden introduced a decision-based support system consisting of 110 recommendations – including the duration of the doctor’s certificate for different medical conditions (6). Below we discuss Norwegian and Swedish doctors’ experiences with the guidelines on the basis of the available literature.
Experiences prior to the guidelines
A qualitative study conducted with 26 Swedish doctors showed that the majority of the group were disheartened by the work relating to doctor’s certificates and feared that they themselves contributed to unnecessary sickness certification (7). In their view, the health service’s weak provisions made it difficult to deal with sickness certification issues. Another qualitative Swedish study revealed considerable differences between patients’ experience of illness and the doctors’ findings and interpretation (8). The doctors felt that a doctor’s certificate could have a negative impact on the course of the illness. In a third study Swedish GPs reported the difficulty of assessing reduced work capacity and the duration and scope of a doctor’s certificate, as well as of having to renew a certificate issued by a colleague (9).
In the case of Norwegian GPs there was no difference in the frequency of sickness certification even though the doctors held different attitudes to socio-political and medical questions (10). A randomised trial with GPs showed that an intervention consisting of a training seminar had no effect on the total frequency of both sickness certification and referrals to voluntary rehabilitation (11). Another study indicated that clinical and demographic relationships and the patient’s self-evaluation were of importance for the assessment of the prognosis (12).
Do guidelines help?
A cross-sectional study from Norway and Sweden published in 2012 included 3,949 Swedish GPs (data from 2008) and 221 Norwegian GPs (data from 2010) (13). Sickness certification was a frequently recurring issue. More than half the doctors in each country experienced this as demanding work.
There are no agreed methods for work capacity assessment in relation to illness. A year after Sweden had introduced guidelines for sickness certification, all Swedish doctors were asked about their use of the guidelines. The questionnaire survey (N = 36,989, to which 61 % of all Swedish doctors responded) showed that 76 % of GPs used the guidelines. Altogether 65 % of these stated that the guidelines provided helpful advice on direct patient contact, and 44 % said that the guidelines were useful in interaction with case officers in the social service and in insurance companies. A total of 32 % asserted that the guidelines improved their assessment skills (14).
Another Swedish study covering 475 doctor’s certificates in 2007 and 501 in 2009 concluded that there was a quality improvement in the doctors’ assessments from 2007 to 2009 (15). The principles of assessment given in the International Classification of Functioning (ICF) were more clearly utilised (16). But only one-third of the certificates contained such assessments. A similar study among Swedish psychiatrists showed that for the most part they found the guidelines difficult to apply (17).
In 2011 a total of 2,516 Swedish GPs (18) reported similar problems as in 2007 (7, 9). In addition, there was a tendency to renew doctor’s certificates because of a long waiting period for additional examinations in the specialist health service. Younger doctors and male doctors, occupational health doctors, psychiatrists and GPs renewed sickness certification beyond the time recommended to a greater extent than other doctors (19). The justification was consideration of the patient.
A review by the Swedish Social Insurance Agency in 2009 showed that the use of guidelines had increased among doctors as well as among employees in public administration (20). The periods of sickness certification were said to have become shorter and there was less diversification regarding their duration. Assessment of sickness certification had become more uniform following the introduction of the guidelines but the total amount of sickness certification remained the same.
The quality of the information in the doctor’s certificates varied. Following the introduction of guidelines, a greater amount of relevant information was found in the certificates from Swedish GPs than in certificates from the other groups of doctors (21), but this did not affect the final result – measured by the extent of sickness certification.
A 2011 qualitative analysis of nine focus group interviews of 48 Norwegian GPs included topics such as diagnostic practice and assessment of work capacity in patients with subjective health complaints (22). The doctors found the sickness certification issue very demanding for this group of patients. Their experience was that the process was partly patient led but that the better the GP knew the patient and the more experience the GP had, the more correct the assessment of the need for a doctor’s certificate appeared to be. Little significance was attributed to the official guidelines.
A panel data study from Norwegian municipalities covering the period 2002 – 10 showed that sickness absence decreased by 2 % if the proportion of graded sickness certification increased by 1 %. Whether this was a result of grading in agreement with the guidelines or whether it was due to other local initiatives is a subject of discussion (23).
A Norwegian study revealed that as regards the assessment of sickness certification it was more fruitful to have a close dialogue with the patient than to make use of medical guidelines and other medical documentation (24). The study also showed that a sick leave prognosis assessed on the basis of medical documentation was less accurate than a prognosis based on direct communication with the patient.
Several European countries have had similar experiences to Norway and Sweden (25, 26).
Summary
Sickness certification is a difficult task for Norwegian and Swedish doctors, and the use of guidelines in clinical practice is very restricted. The studies mentioned showed that guidelines for sickness certification had limited – if any – effect on sickness absence in either country.
