Health care is big business in Australia. Each year 240 million work injury claims are accepted and there are about 2.5 million general practitioner consultations. 96% of workers see a doctor at some point in their work injury journey. 

General practitioners clearly play a critical role and we ask them to do a lot in a complex environment with multiple stakeholders. The Guide for general practitioners to manage work related injury shows just how varied their role is.

It’s in this context that Professor Collie and his colleagues have been looking at the experience of general practitioners in the work injury insurance systems in Australia. This is what they found:

Too much complexity isn’t good for therapeutic relationships

Our work injury insurance system is complex. And it seems that complexity is getting in the way of effective therapeutic relationships between general practitioners and their patients. 

One study identified some of the barriers general practitioners face: 

• They were reluctant to treat patients because of the extra time and administrative burden involved in taking on new patients with work injury claims.
• Delays in payment and low payment for their time and effort compared other fees for service payments
• Difficulty finding specialist and allied health care practitioners to refer patients to because some of those providers refuse to treat workers with work injury claims.
• Their medical opinions being challenged in independent medical examinations.
• Their lack of knowledge and understanding of how work injury schemes operate.
• Lack of continuity of engagement with insurance case managers.

General practitioners have mixed beliefs and attitudes about RTW

In another study of 400 general practitioners, nearly all believed there is a health benefit from early RTW. Most disagreed that patients should only return to work when they’re 100% fit, and most thought their role was to advocate for the patient and help them navigate the work injury insurance system.

So far so good. But concerningly:

• 66% saw the certificate of capacity as being the main way to communicate with other RTW stakeholders
• 77% said conflicting opinions between doctors and people in workers compensation authorities or insurers delay RTW
• 50% agreed that they should have the right to refuse to treat patients with compensable injuries. 

From sick notes to ‘fit notes’

A study of over 120,000 workers in the Victorian work injury scheme looked at first certificates to see if they were written as an ‘unfit for work’ note (sick note), as a ‘fit note’ enabling return to normal duties, or RTW at modified hours or alternate duties. 

It found that:

• 75% of all first certificates were sick notes, 23% were modified or alternate duties and only a very small proportion recommended normal duties. 
• alternate duties certificates were more common for musculoskeletal disorders, and sick notes were more common for mental health conditions. 

Another study found that:

• 12-13% of doctors issued half of all the initial certificates in our work injury schemes. So a small proportion of general practitioners are seeing a lot of injured workers and a lot are not seeing very many.
• certification is a complex clinical and administrative task underpinned by a host of social and systemic factors. 
• case managers and employers view certificates as a therapeutic tool and looked to doctors to recommend RTW, alternate duties or give RTW dates that could help employers get workers back to work.

Some major themes emerged from this study:

• There were different views about whether the role of the general practitioner is to be a patient advocate or to promote RTW.
• There was poor communication or even conflict between stakeholder groups over the content of certificates and general practitioner recommendations 
• Some employers alleged that general practitioners and workers were misusing certification to seek longer periods of time off work.
• There was discussion about the layout and content of the certificate itself. There was no evidence that changing the form leads to any change in certification practice.

Continuity of care needs to be higher

Another study combined heath care data from five work injury insurance jurisdictions into a harmonised ‘multi-jurisdictional database’ to better understand what is happening with the provision of general practice care.

The researchers used this data to look at the issue of continuity of care provided by general practitioners. It found that:

• 28% of 17,994 workers with accepted low back pain claims saw many different general practitioners during their claim
• Low continuity of care was associated with longer disability duration and time off work.

The state of play — where are we at now?

Two documents have been produced that recognise that general practitioners are critical in supporting long term health and social outcomes of individuals. 

A national position statement for general practitioners to support work participation
In October 2020 the Royal Australian College of General Practitioners and the Australasian Faculty of Occupational and Environmental Medicine released the 
Principles on the role of the GPs in supporting worker participation

Clinical Guidelines for the diagnosis and management of work-related mental health conditions in general practice
The National Health and Medical Research council and the Royal Australian College of General Practitioners endorsed Guidelines that give doctors the best available evidence to guide their diagnosis and management of patients with work-related mental health conditions.

Where to from here?

Thanks to this research we now have a large evidence base that tells us much more about the roles and practices of, and the challenges faced by, general practitioners in our work injury schemes.

The next phase is about changing practice. But Professor Collie notes that we shouldn’t just ask doctors to change their practice. There are systemic challenges that come from the way the system functions as a whole—the policies and practices that insurers, regulators, governments and employers have in place.

To get real systemic change, and to increase the value that general practitioners can add to workers’ rehabilitation, we now need to deal with those systemic issues beyond focusing on the role of general practitioners.