In the UK, demand on primary health care continues to rise as the population ages, health reforms focus on shifting secondary care services into the community and the service delivery targets continue to be developed, for example the linking of physician pay to outcomes as with the Quality Outcomes Framework
. Role extension, defined as the ‘substitution of doctors’ traditional role’ can be a useful means of achieving increasing healthcare system efficiency
. In the current setting, this is particularly relevant to primary health care teams, who have evolved to include extended roles for non-medical health professionals including nurses and physiotherapists. Indeed, primary care nurses are increasingly becoming the first point of contact for healthcare and are managing chronic disease
 and physiotherapists often manage patients with minimal input from the general practitioner
Role extension in primary care has generally met positive reviews with advanced roles of primary care nurses deemed successful
. Physiotherapist role extension to act as first point-of-contact practitioners has received high levels of support from GPs and physiotherapists
. However, concerns over the negative impact of role extension in primary care have been raised. For example, previous research highlights that cost savings achieved through the substitution of doctors for primary care nurses may be offset by the lower productivity of nurses and potential increase in doctor-workload due to nurses meeting previously unmet needs or generating demand for care where previously none existed
Boundaries between professions are fundamental to professional identity and as such, occupations often undertake ‘boundary work’ to maintain such identity. By ‘boundary work’ we refer here to the process by which professions attempt to maintain ownership over a sphere of work. In previous studies such practices included the process by which occupations made claims to specialist knowledge or through direct negotiation between occupations to demarcate work boundaries
[7–9]. In the context of changing healthcare policies and organisational structures, boundary work is particularly important to maintain control over a sphere of work. Although there is much interest in evaluating extended roles in primary care, there is a paucity of literature exploring the impact of boundary work on role extension in primary care.
The research presented here sought to explore the views of GPs, practice nurses and physiotherapists towards the extension of sickness certification beyond the medical profession, to identify areas of consensus and disagreement. The notion of ‘boundary work’, a key component of which is the idea of ‘legitimacy claims’, was used as a supporting theory to explain attitudes towards the role extension concept by three groups of health care professionals.
The literature on professional boundaries shows that jurisdictions must be legitimated in the context of where professionals carry out their work and interact with other professions
[10, 11]. The manner of these legitimization practices has taken many forms, indicating the often subtle ways that occupational groups attempt to assert authority over the content and scope of their work. For instance, groups may attempt to protect their claims to a specific jurisdiction through the delegation of ‘unwanted’ tasks to others; thus general medical practitioners (GPs) may pass on routine work to nurses whilst seeking to retain their overarching status as ‘expert’
[12, 13]. Abbott
 argued that by the late 20th Century many professions had come to rely heavily on science as a means of legitimation. In this context, ‘science’ includes both its narrow definition and a broader understanding as rationality and efficiency, a point to which we return below. Several studies have highlighted how distinctions are made when practitioners appeal to the scientific basis of their work
[14, 15]. Science narrowly conceived is, however, not static. Increasing sub-specialisation in medicine is perhaps one manifestation of this
. In any event, such practices always have ‘discursive’ characteristics.
For all of these reasons, we might expect such discourses in the workplace to be dynamic and opportunistic. One possibility is that such discourses exhibit a moral content, the bases of which might range from judgments about different patient groups as ‘good or rubbish’
 to ‘atrocity stories’ in which health visitors distinguished themselves from doctors with reference to the negative attitudes of the latter
. A second possibility is that the notion of ‘science’ might be reconceptualised or reused in various ways. For instance, the notion of ‘clinical isomorphism’
 has been used to signify the readiness of one health profession to adopt the scientific norms of another. Thus, rather than emphasising the relative merits afforded by alternative therapy within the hospital setting (such as its holistic character) practitioners in Mizrachi et al’s
 study sought acceptance from medicine by indicating a need for scientific research to validate the effects of their therapies, and often referred to patients as ‘cases’, indicating that they were adopting a medical discourse. The rhetorical reduction of the patient to a medical case was therefore indicative of their desire to emulate. A rather different example is the broadening of the notion of ‘science’ to encompass wider rationalities such as the effectiveness and efficiency of treatments, or adherence to research-based clinical protocols
[10, 20]. Of course, it is not necessarily the case that professions are consistent in their legitimation discourses; Foley and Fairclough
 found that midwives used discourses of both ‘medicine’ and ‘collaboration’, which they deployed in different ways depending on the context of their work. They reported that use of the language of medicine by midwives was an attempt to establish themselves as equal to doctors, because they too used ‘science’ in their work. However, at other times they placed themselves in a cooperative relationship with physicians as a means of validating their location in the professional status hierarchy.
For all of the above reasons professional work boundaries need to be considered in any analysis of occupational behaviour change, to acknowledge the wider context of the NHS multidisciplinary workforce. The extension of sickness certification to professional groups other than medicine is likely to result in considerable inter-professional boundary negotiation.
Sickness certification in the UK context
In 2011, 131 million days were lost due to sickness absences in the UK
, costing the UK economy £17 billion
. Furthermore, 2.07 million adults of working age were out of work due to long-term sickness absence in 2010 (ONS
). For those unable to work due to ill-health, sickness certificates provide supporting evidence for health-related benefits claims
. In the UK, only medical doctors are legally able to certify sickness absence
 despite evolving extended roles within the primary health care team. GPs are contractually obliged to certify short- and medium-term sickness absence
. Estimates suggest GPs spend six consultations every half-day session discussing work and health and a full-time GP expects to sign approximately ten sickness certificates every week
. In 2001, the Government estimated that extending the authority to certify sickness absence to primary care nurse practitioners would save 2.4 million GP appointments and 51,000 hours of GP time per year. As demands are increasingly placed upon GPs, role extension in sickness certification is an important proposition to consider, particularly as GPs hold mixed views towards their sickness certification role. Some GPs value their participation and feel they are best placed to fulfil this role, others prefer to have the role removed
. Recently, a majority of surveyed GPs thought primary care nurses and physiotherapists should have the authority to certify at least some sickness absence
Evidence demonstrates that work is generally good for health, yet the predominant national philosophy that illness is incompatible with work remains
[29, 30]. In light of this evidence, the Government introduced a strategy on health, work and wellbeing to encourage and assist individuals with ill-health to return to work
[29, 30]. Part of this strategy, the ‘Fit for Work Service’, emphasises a multidisciplinary approach in encouraging an early return to work which includes increasing responsibilities placed upon nurses and physiotherapists. Government policy on managing health and work is becoming more proactive, as opposed to passive in providing disability benefits. There has been the introduction of the Fit for Work Service
 and a new White Paper Fitness for Work: The Government response to “health at work” has set out the Government’s policy in relation to the development of a health and work advisory service providing access to state funded occupational health, improving sickness absence management in the workplace alongside support for healthcare professionals and a reform of the benefits system
. However, a shift towards proactive health and work management in the UK means that diverse skills are required to help people stay in work and manage their work related difficulties. One potential barrier to this could be the possible reluctance of GPs to relinquish their responsibilities for managing work and health to other occupational groups (eg. primary care nurses) or to share this role.
In light of re-focused UK Government priorities towards work and health, the current role extension in primary care and renewed support for role extension in sickness certification to nurses and physiotherapists, this paper seeks to further explore views towards primary care sickness certification role extension, and the potential practical benefits and barriers such a move would involve. We report the views of practice nurses, physiotherapists and GPs to establish whether there is support for role extension, and if so, the key challenges to its introduction. We focus specifically on the relevance of occupational boundaries in role extension policy introduced in the NHS.
Sickness certification: the international context
Research on the role of health professionals and their attitudes towards sickness certification is scarce, and international comparisons indicate wide variations in beliefs and corresponding behaviours among patients and primary care practitioners
[32–38]. Research from Scandinavia has made significant progress in understanding GPs’ attitudes towards sickness certification and work absence. One study found that the strongest indicator of sickness certification is the extent of concordance between patients’ and GPs’ evaluations of reduced work capacity
, whilst a diagnosis of musculoskeletal disease or mental illness increased the likelihood of work absence; perhaps reflecting societal pressure and expectation to exempt people with certain health conditions from participation in work
. Other studies from Scandinavia highlight the difficult challenge of fitness for work assessments in the presence of clinical uncertainty about the patients’ presenting complaint, particularly in the absence of objective signs
. In such circumstances, GPs may be inclined to accept the patient’s complaint and issue a sick certificate
. Research from Scandinavia and the UK also shows that GPs consider work related issues to be less relevant to their primary role and may be ill equipped to assess people’s capacity to work
[42, 43]. In a recent survey, almost two thirds of employers claimed that occupational health specialists, not GPs, were best placed to assess people’s fitness to work
. It is clear from the international literature that significant variation exists in GPs’ assessments of work capacity and decisions to issue a sick certificate. Given the cost implications for global economies, an improved understanding of how the delivery of sickness certification could be improved is needed, and this includes more in-depth research on the possibility of extending authority to other healthcare practitioners
More recently, research in the UK and abroad has begun to examine the impact of illness on work absence, placing greater emphasis on the broader role of employers and organisational policies in facilitating people’s return to work