General practitioners’ management of the long-term sick role Angela Higgins a , Sam Porter b, * , Peter O’Halloran b a Occupational Health, Northern Health and Social Care Trust, Antrim Hospital, Antrim BT41 2RL, Northern Ireland, UK b School of Nursing and Midwifery, Queen’s University Belfast, University Road, Belfast BT7 1NN, Northern Ireland, UK article info Article history: Received 5 December 2012 Received in revised form 27 January 2014 Accepted 29 January 2014 Available online 31 January 2014 Keywords: Ireland Realist evaluation Parsons Sickness absence Sick role Medical role Family physicians Professions abstract In this paper, we use qualitative research techniques to examine the role of general practitioners in the management of the long-term sickness absence. In order to uncover the perspectives of all the main agents affected by the actions of general practitioners, a case study approach focussing on one particular employment sector, the public health service, is adopted. The role of family physicians is viewed from the perspectives of health service managers, occupational health physicians, employees/patients, and general practitioners. Our argument is theoretically framed by Talcott Parsons’s model of the medical contri- bution to the sick role, along with subsequent conceptualisations of the social role and position of physicians. Sixty one semi-structured interviews and three focus group interviews were conducted in three Health and Social Care Trusts in Northern Ireland between 2010 and 2012. There was a consensus among respondents that general practitioners put far more weight on the preferences and needs of their patients than they did on the requirements of employing organisations. This was explained by re- spondents in terms of the propinquity and longevity of relationships between doctors and their patients, and by the ideology of holistic care and patient advocacy that general practitioners viewed as providing the foundations of their approach to patients. The approach of general practitioners was viewed nega- tively by managers and occupational health physicians, and more positively by general practitioners and patients. However, there is some evidence that general practitioners would be prepared to forfeit their role as validators of sick leave. Given the imperatives of both state and capital to reduce the financial burden of long-term sickness, this preparedness puts into doubt the continued role of general practi- tioners as gatekeepers to legitimate long-term sickness absence. Ó 2014 Elsevier Ltd. All rights reserved. 1. Introduction Sickness absence is a phenomenon of concern to industries and governments throughout the advanced industrial world (Evans and Walters, 2003). That said, levels of absence vary markedly across countries. Thus, Osterkamp and Röhn’s (2007) analysis of sick rates across countries affiliated to the Organisation for Economic Co- operation and Development (OECD) discovered that the average number of days lost to sickness absence per employee per annum was five times greater in Poland than it was in the USA. In this paper, we wish to concentrate on Britain, the absence rates of which lay at the lower end of the spectrum, but which nevertheless are the subject of considerable governmental and commercial concern (Black, 2008; Confederation of British Industry, 2010). While difficulties of enumeration make precise figures con- cerning sickness absence rates impossible, there is consensus that they are subject to a downward trend (Black and Frost, 2011; Confederation of British Industry, 2010). Yet even using the lower current estimate of 4.9 days per annum, this still involves a loss of 140 million working days, or 2.2 percent of all working time (Black and Frost 2011). In financial terms, direct costs to employers in 2010 were estimated at £16.8 billion, and indirect costs at £13.2 billion (Confederation of British Industry, 2010), with state spending on health-related benefits adding another £13 billion (Black and Frost, 2011). Like many OECD countries, a significant proportion of the workforce (approximately 20 percent) is employed in the public sector. Absence rates in this sector are roughly 50 percent higher than in the private sector, leading to a wage cost of approximately £4.5 billion per annum. Among the reasons proffered for the higher levels of sickness absence is the more generous long-term sick pay arrangements that public sector workers tend to enjoy once they have been certified by their general practitioners (the British term for community-based primary health care physicians) as being legitimately absent (Black and Frost 2011). This frequently consists of an allowance of six months on full pay and a further six months on half pay. * Corresponding author. E-mail addresses: Angela.Higgins@northerntrust.hscni.net (A. Higgins), s. porter@qub.ac.uk (S. Porter), p.ohalloran@qub.ac.uk (P. O’Halloran). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2014.01.044 Social Science & Medicine 107 (2014) 52e60