When it comes to illness, sometimes the end is just the beginning. In ‘Recovery’, GP and writer Gavin Francis explores how – and why – we get better. In this extract, he discusses work stress, the sick note, and why being given permission to recover is so important.
When I started out as a GP in Edinburgh, there was a story told about one of my predecessors. The story came from 30 or 40 years ago, the era of single-handed practices, and the GP was overworked.
To reduce the pressure on his appointments, he devised a method of dealing with sick-note certificate requests: every week he’d pre-sign one pile of blanks granting a week off work, and another pile granting four weeks off. Then he’d go out on his rounds and leave the receptionists to distribute the notes as they saw fit.
This approach, I heard, had a happy side effect: patients who had previously been rude or aggressive towards the receptionists became polite and respectful overnight.
Sickness certificates are something GPs have almost no training in providing, and are, in essence, prescriptions to take time off work to rest. Doctors are in a contradictory position: obliged by law to provide the government with judgements about capacity to work, but also obliged by their professional regulator to “work in partnership with patients” and “make the care of your patient your first concern”.
We are supposed to work hard to maintain our therapeutic relationship with our patients, an ambition that can sometimes be at odds with the state’s request that we pass judgement over them. Adrian Massey, an occupational health doctor who has written about this inherent paradox in doctors’ roles, sums up the situation in his book ‘Sick-Note Britain’, as “doctors make terrible referees, but excellent coaches”.
In 2013 a social attitudes survey found that over 80 per cent of people agreed with the statement “a large number of people these days falsely claim benefits”. But the UK government says that just 1.7 per cent of sickness-benefit claims are fraudulent. Of those 1.7 per cent, a full third are thought to be overclaimed through “genuine error”.
Finding the strength to live with illness
During my first year in training as a GP, I got sick. I’d worked for many years in hospitals, had already qualified as a trainee in emergency medicine, but the intensity and breadth of problems I was learning to face in my new role as a doctor in the community felt to me overwhelming.
An old, recurrent problem with my sinuses flared up, leaving me with a ceaseless, drilling headache above the eyes that sapped all of my energy. An MRI scan showed that I needed surgery, which might take months to arrange. In the meantime, I had my GP training to complete.
I couldn’t do anything to hurry up the arrival of my operation date, but I could do something about my exhaustion and my levels of stress. Rather than stop work altogether, I dropped to a three-day week – each day in clinic would be followed by a day off to recover.
The headache was as bad as ever, but with more time to rest and recuperate between clinic days, the pain bothered me less. Knowing I’d have the breathing space of a day at home meant that I was able to give my best to my patients on those days I was in the clinic.
I persuaded myself that there was no point risking burnout for the sake of sticking to a schedule of someone else’s making.
My training would be delayed – it would now take longer than a year for me to be signed off as a competent GP – but I persuaded myself that there was no point risking burnout for the sake of sticking to a schedule of someone else’s making. And I qualified all the same, albeit a couple of months late.
The operation, when it came, was successful, my headaches were cured, and I had learned a valuable lesson. We need strength and energy to live with illness; reducing my workload gave me the reserves I needed not just to live with chronic pain, but to begin on the path towards recovery from it.
Benefits and the compassionate society
Archaeologists who study the bones of our distant ancestors tell us that there was no golden age – for most of human history, most people worked hard all their lives and died young. Their bones are ridged with the attachments of strong muscles, their joints worn away by toil. Many were lucky to reach the age of 40.
By the Victorian era it was proclaimed that charity began at home, but at the same time an anxiety took root that generosity bred idleness and corruption. Even the sick had to work for their keep – charitable provision was modest and was delivered through ‘workhouses’ or ‘almshouses’, where life expectancy was shockingly low.
Many of the patients I sign off from the obligation to find a job could undoubtedly work in some capacity, at something, if support were available to help them to do it. And work aids recovery in all sorts of ways, granting through physical and mental effort a sense of purpose, satisfaction and social connection, as well as a livelihood.
If I could sign my patients up to a supportive back-to-work scheme, rather than simply signing them off sick, I would. But the truth is, the kind of support that is needed to help bring many people back into work is more expensive than the system of sickness benefits, and so there’s little incentive for governments to pursue it.
If we aspire to a more civilised and compassionate society than the one of Victorian workhouses, then we have to accept that the issue of who can work and who can’t isn’t just a question of objective tests, but one of compassion, society and culture.
Who can work and who can’t isn’t just a question of objective tests, but one of compassion, society and culture.
Convalescence needs time, and the value we place on that time ultimately comes down to what our politicians will support. We are better at providing sickness benefits than we used to be – the half-century between 1945 and 1995 saw UK spending on sickness benefits increase ninefold – but there is still a long way to go to provide a truly supportive welfare safety net that allows everyone, rich or poor, to recover to the best of their capacity.
There are many politicians who see today’s modestly increased provision of benefits as evidence of a sick society, but I prefer to take it as heartening evidence that we are slowly (too slowly!) becoming a more compassionate society.
Neither are UK payments to support sickness absence an unsustainable drain on the state, as is sometimes claimed. These payments are regularly demonised in the tabloid press, but they make up less than 0.002 per cent of the sum that was paid out to banks following the financial crash of 2008.
It’s another idiosyncrasy of sickness certification that its rules are set in legal terms, thrashed out in Parliament or the courts in an adversarial environment that is profoundly at odds with the collaborative nature of medical consultations. And the alternative to this kind of provision would be to tolerate widespread destitution as a result of illness.
The politician Aneurin Bevan, who was pivotal in creating the UK’s National Health Service, championed the idea that illness is “neither an indulgence for which people have to pay nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community”.
This quote didn’t actually come from the mouth of Bevan, but was written by a sociologist called T H Marshall as a summary of guiding principles of the welfare state. It has been widely shared and repeated because at heart we recognise its truth: illness is not just a personal calamity, but a social one too; helping ease its effects is something we all must take a part in, as a community.
About the contributors
Gavin Francis has worked across four continents as a surgeon, emergency physician, medical officer with the British Antarctic Survey and latterly as a GP; he has described the pandemic response of 2020 as the most intense period of his 20-year career in medicine. He’s the author of the Sunday Times bestseller ‘Adventures in Human Being’, which was a BMA Book of the Year, and ‘Shapeshifters’. His books have won the SMIT Scottish Book of the Year Award, the Saltire Award for Non-Fiction and been shortlisted for the Ondaatje and Costa Prizes. He also writes for the Guardian, The Times, the London Review of Books and Granta. He lives in Edinburgh with his wife and children.
Steven is a photographer at Wellcome. His photography takes inspiration from the museum’s rich and varied collections. He enjoys collaborating on creative projects and taking them to imaginative places.