The following is a summary prepared by RSMH MG based on the actual published material. The source material (in swedish) is available for download elsewhere on this page.
The government decided on June 9, 2022, to appoint a special investigator and initiate an investigation into the significance of medical certificates in sickness benefit cases. The investigator was tasked with analyzing the reasons why doctors and officials at the Swedish Social Insurance Agency (Försäkringskassan) sometimes make different assessments of work capacity and whether doctors' assessments of work capacity should carry more weight in sickness benefit cases.
The investigation was also to analyze the importance of collaboration between healthcare professionals for doctors' work in issuing sick notes. The investigation was to propose how interprofessional collaboration could be developed and whether it could facilitate doctors' work with sick notes and strengthen their assessments of work capacity, the need for sick leave, and rehabilitative measures. Furthermore, the investigation was to analyze how the information in medical certificates could be improved and whether employers could receive more purposeful information to facilitate rehabilitation and job adaptation.
Assessment of Work Capacity:
In most cases, sickness benefits and return to work after short sick leaves are approved. Collaboration between doctors and officials works well in such straightforward cases. Medical certificates and doctors' assessments are crucial, and complex cases sometimes lead to differing assessments of work capacity. The reasons include limited resources for thorough assessments. Försäkringskassan needs to improve methods to reduce variations and increase clarity in decisions. The doctor's role in assessing work capacity is central. Particularly in cases of mental ill-health, attention and resources are needed for quality assessments. The focus should shift toward facilitating return to work, and doctors' and officials' assessments should guide different situations.
Problems arise when the treating doctor's assessment is reviewed by Försäkringskassan doctors, who have only met the patient/user in extreme exceptional cases.
Collaboration Between Healthcare Professionals:
Collaboration between different healthcare professions is important for sick leave and rehabilitation, with a focus on individual needs. The doctor's role is central in sickness certification decisions, with responsibility for assessing work capacity and the need for sick leave. Collaboration between professions can provide valuable information, but ensuring doctors' competence is most important. If needed, doctors can collaborate with other professionals, including in-depth investigations. Collaboration should be needs-based, and regular use of assessment teams is not recommended due to resource limitations. In complex cases, the possibility of referring to specialized insurance medicine should be considered and developed.
Information to Employers:
Employers need information about why an employee is on sick leave, its impact on work capacity, and any medical risks. This requires doctors to have insurance medicine expertise to justify sick leave. Healthcare can suggest workplace measures based on the health condition, but employers are responsible for planning and implementing them. Occupational health services play a crucial role but are underutilized. Inadequate collaboration and communication between employers and healthcare need to be addressed through enhanced coordination within healthcare and the development of digital information channels.
The Investigative Proposal:
Clarity in tasks and information regarding sick leave and insurance
The tasks must be clarified for better cooperation in the sick leave and rehabilitation process. Clarification is needed for the doctor to assess the reduction in work capacity during sick leave within the framework of medical responsibility. Försäkringskassan requires relevant medical information for compensation decisions, even if it is only part of the basis. Increased knowledge is needed about the nature of sick leave, the roles of various actors, and how the health insurance system operates. Collaboration between Försäkringskassan, Socialstyrelsen, and other stakeholders is necessary to improve information and knowledge sharing on these matters.
Effective and purposeful certificate and information management
Medical certificates are crucial for Försäkringskassan and employers to take appropriate actions during sick leave. The handling of certificates needs improvement, both in terms of content and technology. Ambiguities in the certificates must be resolved for them to function effectively and contribute to legal and patient safety. The proposal is that Försäkringskassan, in consultation with Socialstyrelsen and other relevant stakeholders, develops more purposeful medical certificates. For short-term sick leaves, simpler certificates should be considered. The development of digital certificate management is essential, and governmental measures are required to establish a national infrastructure. The E-Health Authority should receive a long-term mandate for this purpose.
Functioning cooperation for return to work
Effective collaboration between healthcare, employers, the Employment Service, and Försäkringskassan is crucial in assisting individuals to return to work. The investigation proposes that coordination efforts, including dialogue with employers, should be strengthened. The opportunities of digitization for information exchange between the stakeholders and the individual should be explored. Assessing the reduction of work capacity and the possibilities for returning to work can be challenging, so it is suggested that methods for practical testing of these conditions during sick leave should be examined. The vital role of occupational health services is emphasized, and the state should ensure long-term competence supply and access to specialized occupational medical doctors for occupational health services by addressing responsibilities and funding issues.
Secured insurance medicine expertise and knowledge
To improve the sick leave and rehabilitation process, actions are required to ensure competence and support for healthcare and Försäkringskassan employees. A national competence center for insurance medicine should be established, supported by the National Board of Health and Welfare, to enhance knowledge and effective practices. The introduction of insurance medicine as a specialization within physicians' specialist training should be considered, as well as the development of specialized insurance medical services within healthcare to support regional expertise. Försäkringskassan needs to develop support and conditions to increase transparency and reduce variations in assessments. Research-based knowledge about sick leave and return to work should be strengthened and coordinated. Continuity and long-term commitment in the field of insurance medicine within universities and colleges are necessary.
Right organizational conditions for healthcare professions
Healthcare professionals need the right organizational conditions and resources to carry out their tasks within the sick leave and rehabilitation process. It's important to ensure competence, time, and the opportunity to consult specialized expertise when needed. The National Board of Health and Welfare should regularly monitor the conditions and efforts of these professionals, and the government should integrate the efforts of healthcare into the reform work for good and close care. This is crucial to develop the conditions and collaboration of professionals within the sick leave and rehabilitation process.
Collaboration for a purposeful sick leave system
The structural collaboration between the Swedish Social Insurance Agency (Försäkringskassan) and healthcare actors in the area of sick leave is crucial for the functionality of the sickness insurance. The inquiry assesses that more effective working methods in collaboration are needed to identify and address systemic issues that have contributed to the need for this investigation.
There is a significant need for close cooperation in ongoing and proposed development work to ensure that measures are implemented purposefully and with a holistic view. Moreover, the implementation of changes needs to become a natural part of collaborative development.
The inquiry suggests that the Swedish Social Insurance Agency and the National Board of Health and Welfare (Socialstyrelsen), together with relevant stakeholders in the healthcare sector, develop the forms of national collaboration regarding joint development related to sick leave and insurance medicine. The results of this collaboration should be continually monitored by the government since it is crucial for the functionality of the sickness insurance.
The area of sick leave is influenced by several extensive ongoing and planned development processes, such as the development of national infrastructure, transitioning to good and close healthcare, and other developments initiated by various stakeholders, as also proposed in this report. Therefore, we propose the appointment of a national coordinator for a limited period, acting from a broad systemic perspective, driving development, and contributing to ongoing dialogue among the responsible actors, and supporting the government's ability to follow up on the measures within the field of sick leave.
The consequences:
The investigation proposes extensive measures to improve the sick leave process and support return to work. These are expected to result in more accurate assessments and better support for individuals. Regions receive financial support for the development of specialized insurance medicine. The proposals for information and certificate management streamline administration and free up resources. The individual's need for sick leave is expected to be assessed more accurately, improving support for return to work, promoting gender equality, and enhancing the individual's understanding of the system. Tasks are assigned to state agencies such as Försäkringskassan and Socialstyrelsen. Further investigations will improve dialogue with healthcare and support individual return to work. Overall, these measures aim to facilitate the return to work.