From the Malta Independent on Sunday
Those damned sickness certificates
Daphne Caruana Galizia
Sources close to the Ministry for Social Policy have leaked information to the newspapers that shows what at first appears to be the rampant fraudulent issuing of sickness certificates by certain doctors. This allows their patients to claim benefits and to take time off work. One particular doctor, the sources said, has issued more than 3,500 such certificates in eight months, and warning letters have been sent to around 200 doctors who have been issuing an “excessive” number of sickness certificates for the same condition. It has also been said that there is a significant rise in the number of certificates issued during the shooting season, which specifically implies fraud.
The reaction from the Medical Association of Malta has been immediate and harsh. The MAM says that it has been involved in “constructive” talks with the Ministry for Social Policy, to ensure more stringent control of the sick leave certification system. It seems that now the MAM has taken serious offence at the leaking of figures and information to the media, deploring what it describes as “unofficial leaks of incomplete data and unscientific conclusions which put the medical profession in a bad light and embarrass the government unnecessarily.”
It is hard to see how the government is embarrassed here, rather than the medical profession, unless it is by the suggestion that the government cannot keep confidential information out of the hands of those who might be tempted to leak it. But why assume that the information has been leaked against the wishes of the ministry? Reading through the angry statement issued by the MAM, it is easy to pick up on the points it is trying to make. For example, patients discharged from hospital after suffering heart attacks, major operations or fractures are expected by the government to get themselves a fresh sickness certificate every week. Besides causing them (and their doctors) considerable inconvenience over and above that of their illness or disability, this repeat issuing of certificates, sometimes for up to several months, will show up on the computerisation as somehow suspect. Another point that the doctors’ association has made is that those who are chronically ill must wait for months before their case is considered by the invalidity board, meaning that one such patient may have to collect up to 22 sickness certificates or so.
Another accusation made by the source close to the ministry is that those doctors who issue the most certificates are the ones who declare the lowest income for tax purposes. At first glance, this looks as though they are receiving undeclared payment for issuing fraudulent certificates, and lots of them. But the doctors’ association has since made the reasonable point that doctors who work at State health centres, or who are employed by private companies with a large workforce, have a fixed salary that is not high at all. They are also the ones who issue the most certificates precisely because of the specific nature of their work. You can see why the doctors’ association is annoyed, but this still does not explain why the number of certificates peaks during the shooting season, or the fact that it has become almost routine with some doctors to issue sickness certificates to their patients after a telephone call requesting one, and without verifying whether the patient is/was in fact ill.
The MAM has admitted “there are a few individuals who fake illness and who place doctors in a difficult position” and has said that “the vast majority of certificates cover three days or less, which shows that doctors generally are very considerate and judicious.” But surely that is not enough? I don’t think anybody except the most obtuse would have read the original story about the leaked information on sickness certificates and assumed that all doctors are corrupt, suspect, and easy with their signature. The story clearly pointed to certain unnamed doctors who seem to have implemented a sickness certification system that appears abusive at first, but which may, on closer analysis, turn out to be quite as the association has described; tangled up in bureaucracy that demands a new certificate every week for chronic patients.
However, we are not so naive that we believe there is absolutely no fraud, and the cavalier attitude of some doctors to sickness certification may be due to the fact that there are no stiff penalties for doing so. This is where the association should step in and, instead of performing only as a sort of union for its members, act also as a force for discipline. A false sickness certificate is an act of fraud both by the doctor issuing it, and by the person in whose name it is issued. There are no two ways about it – no u ejja, x’differenza taghmel.
In a way, it is the sickness certification system itself that is leading to fraud and abuse. Let’s take the case of schoolchildren. When they are absent from school for more than three days, their parents receive a request for a doctor’s certificate. The school makes this request on behalf of the education authorities. One can understand that this is done to avoid abuse of another sort: keeping children away from school for reasons other than sickness. The authorities want that certificate to prove that the child was indeed ill. I have run into this problem fairly often over the past few years. Long gone are the days when I called the doctor out for every bout of temperature, cough or sore throat. Now anybody who is ill just stays home for a week, not just because they don’t feel up to school but also not to spread germs, and that’s it.
I think I should know by now what’s worthy of calling the doctor out, and what is just a waste of his precious time. Yet my explanation that I don’t have a sickness certificate because the sickness did not merit calling the doctor out is met with a blank. Because I refused to waste the doctor’s time and my money simply to have a piece of paper to prove to the government that my child was ill, and not working in the fields or out shooting birds with his father, I found myself instead writing “To whom it may concern” letters explaining this, complete with ID card number and details. At their independent secondary school, these letters were accepted.
Now this problem has been carried over to Junior College, where the measures are more stringent. A week’s bout of flu was followed by a stiff demand for a doctor’s certificate, and my signed, ID-card-numbered note of explanation that no doctor was called was not accepted. I found myself doing the very thing I am so dead set against: going to our doctor, asking him to take on trust my explanation that my son was ill, and having him write out a certificate when he hadn’t seen him and the sickness was long past. I hate that kind of thing: it seems like so much pointless bureaucracy. This is where the “difficult situations” described by the MAM arise, though that is a minor incident and there are far more serious ones. Quite clearly, in this particular case my letter of confirmation of illness should have carried more weight than that of the doctor who hadn’t even seen the boy, but bureaucracy is an animal quite apart.
The demand for sickness certification is not just opening the way for a great deal of abuse – the “innocent” sort of abuse I have just described, besides real fraud – it is also placing far too much purposeless demand on the time of doctors who are already overworked. Why should schoolchildren with a tickle in the throat or a chesty cough be obliged to jam up the waiting-room at overburdened health centres, when they don’t need a doctor for anything other than a sickness certificate? Surely a note from the parent should be enough? The education authorities can be adequately alerted to abuse by repeated absence. An absence of five days in January or February is most unlikely to be anything other than illness.
There are enough difficulties between the health authorities and doctors in general, and starting off this kind of row now will achieve nothing positive. All it takes is a smidgen of good will on both sides, and the admission by all that doctors are not always abusive, just as they are not always right. After all, if there is a request for a fraudulent sickness certificate, all the doctor has to do is refuse to issue it. It shouldn’t be any different to the issuing of false VRT certificates or making fraudulent insurance claims. But then there must also be a certain amount of rationality, and parents should not be forced to call out the doctor – or to clog up his waiting-room – when their children do not need medical attention, but only a certificate to prove that their parents are not liars.