The cost of saying no: general practitioners’ gatekeeping role in sickness absence certification

Abstract

Background General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. Methods Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke’s thematic analysis approach. Results Our results indicate that GPs’ sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs’ opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs’ available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. Conclusion Our study suggests that GPs’ decisions about sickness certification is largely driven by patient preferences. The GPs’ gatekeeping function is limited to negotiations about grade and duration of absence spells.

Time is money: general practitioners’ reflections on the fee-for-service system

“…Some of the questions were asked as yes/no questions to first establish whether the GPs agreed/disagreed with a statement, followed by open-ended questions asking the participants why or ask them to give examples to gain insight into their perceptions and opinions. Data collection for this study was conducted concurrently with another study on GPs’ gatekeeping role in sickness absence certification, allowing for efficient gathering of data for both studies [ 12 ]. In order to assist non-Norwegian speaking readers with information on which specific fee codes and their corresponding wording that are relevant at the time this study was conducted, we have included a list of fees mentioned in supplementary file 2 .…”

“…There is a rich literature on GPs’ gatekeeping role in Norway and GPs describe it as very challenging and uncomfortable [ 9 – 11 ]. Qualitative studies have found that GPs' gatekeeping decisions in sickness absence certification are, in practice, largely patient-driven and that GPs' role is limited to negotiations with the patients [ 9 , 12 , 13 ]. Studies have emphasised financial incentives as an aspect that may have impact on how the gatekeeping role is practiced [ 10 , 12 , 14 ].…”