What is the problem with sick leave in Catalonia?

BarcelonaAlba Cuberas, a family doctor at the Manresa-4 Primary Care Center (CAP), sees a patient with intense back pain. She gives him a short sick leave and anti-inflammatory medication, but there is no improvement. With an X-ray, the rheumatologist recommends rehabilitation. "But nobody calls him. I see him once a month, and he's told me two months ago that he hasn't started the sessions," she says. In Sant Pol de Mar, Martín Cebollada suspects a patient may have a herniated disc and, to be sure, orders a CT scan. The wait is six months. "But he has debilitating pain, and I can't know for sure how serious it is; he can't go to work," he states. At the Manso Primary Care Center (CAP) in Barcelona, ​​Eva Segura is monitoring a patient on sick leave for severe depression, with a history of suicide attempts. In the fourth month, she receives the first discharge proposal from the insurance company, but she has just started psychiatric treatment, and the doctor rejects it. In the fifth month, the same request arrives, and she rejects it again. This happens four times. But against her advice (and that of the psychiatrist), the Catalan Institute of Medical Assessments (ICAM) sends the patient back to work, and the company, shortly afterward, declares her unfit. "She loses her job, and her health deteriorates significantly," she explains.

These three examples are real and were explained by professionals at the headquarters of Doctors of Catalonia, the largest doctors' union. They coincided on Thursday because a sectoral meeting was being held to address the challenges of primary care, and the meeting was marked by the Health Department's proposal to provide incentives to primary care centers (CAPs) that manage to reduce sick leave due to mental health issues and musculoskeletal injuries—which are the majority and can last up to a year and a half.

None of the three interviewees were surprised by the measure: they say it's where the department is focusing its efforts; that last year they already tried to increase the number of approved claims received from insurance companies and prioritize them: they had to be answered within a maximum of three days. However, the Catalan Health Department (Salut) maintains that the incentives are intended to improve healthcare pathways, not to influence medical decisions, and that they are already part of the "performance-based compensation" system.

The number of sick leaves granted has steadily increased over the last decade. In fact, the rate of temporary incapacity (TI) per thousand workers is at an all-time high: 53 in Spain and 52 in Catalonia. In 2012, the rate was 20 cases, and in 2019 it was 35. "But in 2006, before the crisis, there were also 50 sick leaves per thousand workers," Segura points out. Currently, there is no increase in the average duration of TI—it has remained at around 38 days since 2012—but long-term TI is on the rise.

The debate about whether too many sick leaves are being granted is not new, but primary care physicians as a whole have denounced the announced compensation, arguing that it calls into question and conditions medical judgment and blames professionals for problems caused by the "blockage" of the healthcare system, which limits diagnostic testing, referrals to specialists, and the prescription of medications. Doctors lament that the regional health authority and the National Social Security Institute (INSS) distrust them and the public.

Good or bad use of sick leave?

"It's clear there's a problem when growth has been continuous for 10 years," says Sergi Macip, professor of psychology and education sciences at the UOC and an expert in work and organizational psychology. The causes are multiple, and he points to four: the inverse relationship between unemployment and sick leave—when unemployment rises, sick leave falls and vice versa; difficulties in achieving work-life balance; the reduction of stigma surrounding mental health; and the mismatch between an employee's skills and their job.

Doctors emphasize that they have 10 or 12 minutes to examine, evaluate, and weigh the information provided by the patient—symptoms, profession, and work-related responsibilities and risks—and decide whether sick leave is warranted, calculate an optimal duration, and adjust it to the patient's job duties. "It's not the same if someone sprains their ankle and works sitting in an office as if they unload trucks," says Cebollada. However, they lack the information that depends on company occupational health and safety services, which hinders the gradual return to work. They also criticize the software for the difficulty in accurately coding a pathology and the worker's profession.

According to Macip, the types of work-related illnesses that have grown the most are the most difficult to quantify objectively, such as mental health problems, which have increased by 87% in the last six years "throughout the country and in all productive sectors." Furthermore, there is a perception that there are more repeat offenders; workers who take two or more sick leaves per year. "The regional health ministry focuses on the medical aspect, which is where it can intervene. It cannot intervene in the business aspect, which would involve examining what the company can do to prevent or reduce sick leave, which does depend on the employee's choice," argues Macip, who believes that, in situations of workplace distress, sick leave is being seen as a way to cope.

"Are there many or few patients who misuse sick leave? They exist, but no one has measured it. If there are few, the department's measure will have a small economic impact," states Ramon Cunillera, president of the Catalan Society of Healthcare Management. Most "don't lie" to the doctor or try to force an unjustified leave, but, given the lack of other leave options or social resources, they can use sick leave. "This doesn't necessarily mean they want to misuse the benefit; it simply means they have a problem and express it to the manager or the doctor," he emphasizes.

The CAP-mutual relationship

The employers' association Pimec applauds the pilot program for incentives, estimating that sick leave can cost around €33.34 billion annually, equivalent to 10.5% of GDP. However, doctors agree that "pressuring" primary care centers (CAPs) will not solve the problem; instead, realistic changes are needed to address the lack of resources, the lack of coordination between stakeholders, and the increasing workload in CAPs. For example, monthly follow-up for patients on sick leave due to a heart attack or cancer could be carried out by the specialist who sees them; sick leave of up to three days could be self-reported; or occupational illnesses covered by mutual insurance companies should not be treated as common illnesses by CAPs. "With this, we could reduce the amount of sick leave we manage by 50%," says Segura. In fact, the lack of coordination between the public health system, mutual insurance companies, and employers is another major problem. "The employee receives sick leave based on the patient's version of events, but the company's version is often different," says Macip. "Ninety percent of our diagnoses are based on what we're told, the examination, and our experience. If a patient tells me they can't go to work because they're having an anxiety attack, I have to believe them," argues Cebollada. In this regard, the doctors state that the mutual insurance companies—which have more information about patients than they do—can conduct tests to expedite the process or have their specialists perform assessments.

Marga León, a doctor in the Terres de l'Ebre region, explains that between 2022 and 2024 she participated in a pilot program to create an IT unit for musculoskeletal disorders. The team—comprised of three doctors, an administrative assistant, a nurse, and a physiotherapist—allowed for more intensive follow-up and greater coordination with physiotherapy services, the Catalan Institute of Medical Assessments (ICAM), and private health insurance companies. "We even reached an agreement with the insurance companies that if we requested a supplementary test, they would carry it out within a week," she says. This model allowed for more time per patient (around 20 minutes) and showed "good results" in reducing long-term sick leave and facilitating adapted returns to work, "but it was dismantled without warning," León laments.