Lara Shemtob Academic Clinical Fellow in General Practice, Department of Primary Care and Public Health, Imperial College London; National Institute for Health Research Applied Research Collaboration Northwest London, Imperial College London.
Kaveh Asanati Consultant Occupational Physician and Visiting Professor in Occupational Health, Department of Primary Care and Public Health, Imperial College London; National Institute for Health Research Applied Research Collaboration Northwest London, Imperial College London.
The Department for Work and Pensions has recently announced legislative change that will allow a wider range of healthcare professionals to authorise fit notes.1 Media coverage of this policy change has been centred around the benefit of freeing up appointments for GPs to handle more complex presentations.
In today’s model of primary care, patients are treated by a range of healthcare professionals. The ability to discuss a fit note with the treating clinician — whether they are a physiotherapist, occupational therapist, pharmacist, or practice nurse — rather than book a separate GP appointment is more efficient and allows continuity for patient and clinician. However, viewing the changes in regulations simply as a reduction in bureaucracy is limited and unlikely to lead to good practice in use of the fit note.
How do we use the fit note in practice?
“The most socioeconomically vulnerable workers … are least likely to have access to occupational health.”
The purpose of the fit note is not only to certify sickness absence, but to help patients keep working during or return to work following a period of ill health. Work is generally good for our health, and avoiding long-term sickness absence has benefits at an individual and societal level.2
Occupational health (OH) is excluded from what the NHS provides, and some research suggests only 50% of workers have access to OH through work.3 This means that a significant proportion of the workforce could be dependent on primary care for advice on health and work. The most socioeconomically vulnerable workers, such as those in insecure employment, are also least likely to have access to OH.
Data from NHS Digital demonstrates it is consistently challenging for GPs to make use of the fit note in primary care; 95% of fit notes are signed as ‘not fit’ for work.4 The purpose of introducing the fit note over a decade ago was to encourage and allow GPs and patients to consider whether they may be fit for some work. Very limited use of the ‘may be fit for work’ option suggests that despite this, the vast majority of the time, the fit note is still being used as a sick note. Around one-third of fit notes are signed for 5 weeks or longer, by which time 20% of patients are unlikely to return to work.5
In the current healthcare landscape, primary care is leant on to provide OH advice given the lack of universal coverage. However, without adequate resources — from training in OH to time to discuss occupational issues in a 10-minute consult — data on the fit note suggests GPs have struggled to use it to its full potential.6
“Around one-third of fit notes are signed for 5 weeks or longer, by which time 20% of patients are unlikely to return to work.”
What does a wider range of healthcare professionals authorising fit notes mean for primary care?
These changes are an opportunity for the primary care workforce and patients to learn about OH and how the fit note can be a powerful tool to keep people working. Patients could benefit from seeing a broader range of healthcare professionals for fit notes according to their presentation, such as seeing a physio for musculoskeletal issues affecting work.
For motivated healthcare leaders in primary care, there is an opportunity to begin addressing the gap in OH provision by building out services at primary care network level. The Additional Roles Reimbursement Scheme could provide funding for multidisciplinary staff running dedicated primary care OH and complex fit note clinics working across practices, for example.7
On the other hand, these changes could perpetuate under-use of the fit note to its full potential in primary care. For some multidisciplinary team members, the OH skill sets required to complete fit notes, such as taking an occupational history, will not have been covered in their professional training. Training will be offered to up-skill the workforce, but it will not be mandatory, and GPs may need resources and support to teach their teams best practice.
“… patients and primary care teams must be on board with the fit note as a tool to help return to work … “
Media coverage of the changes has portrayed the fit note (reported in several news outlets as the ‘sick note’) as a low priority area, given to other members of primary care teams in order to save GPs time. There is a danger that this change will depict fit notes as a simple administrative task, not one that requires targeted data gathering, negotiation, and shared management to achieve a good outcome for a patient’s health.
These changes bring an opportunity to improve access to OH support for patients, addressing a gap in NHS provision. To achieve this, patients and primary care teams must be on board with the fit note as a tool to help return to work or keep working through a period of ill health where safe and appropriate.
The challenge is that the majority of GPs may not have the resource, training, and interest to lead on this transition in their practices. In order to use these changes to promote health at work for patients and society, they must be met by wider changes in the healthcare landscape. This includes investing in OH teaching in undergraduate and postgraduate healthcare curricula,8 promoting the role of OH services to employers, healthcare professionals, and patients,9,10 and, importantly, public messaging about health and work and the important role the fit note can play in facilitating return to work.
1. Department for Work and Pensions, Department of Health and Social Care, Smith C. More healthcare professionals given powers to certify fit notes. 2022. https://www.gov.uk/government/news/more-healthcare-professionals-given-powers-to-certify-fit-notes (accessed 6 Jul 2022).
2. Waddell G, Burton AK. Is work good for your health and well-being? 2007. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/214326/hwwb-is-work-good-for-you.pdf (accessed 6 Jul 2022).
3. Department for Work and Pensions. Health and wellbeing at work: a survey of employees. 2015. https://www.gov.uk/government/publications/health-and-wellbeing-at-work-survey-of-employees (accessed 6 Jul 2022).
4. NHS Digital. Fit notes issued by GP practices. 2022. https://digital.nhs.uk/data-and-information/publications/statistical/fit-notes-issued-by-gp-practices (accessed 6 Jul 2022).
5. Black C, Frost D. Health at work — an independent review of sickness absence. 2011. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/181060/health-at-work.pdf (accessed 6 Jul 2022).
6. Shemtob L, Asanati K. How to get the most out of the fit note. Br J Gen Pract 2021; DOI: https://doi.org/10.3399/bjgp21X717665.
7. NHS England, NHS Improvement. Network Contract Directed Enhanced Service: Additional Roles Reimbursement Scheme guidance. 2019. https://www.england.nhs.uk/wp-content/uploads/2019/12/network-contract-des-additional-roles-reimbursement-scheme-guidance-december2019.pdf (accessed 6 Jul 2022).
8. Academy of Medical Royal Colleges, Royal College of Nursing, Allied Health Professions Federation. 2019 healthcare professionals’ consensus statement on health and work. 2019. https://www.aomrc.org.uk/wp-content/uploads/2019/04/Health-Work_Consensus_Statement_090419.pdf (accessed 6 Jul 2022).
9. Department for Work and Pensions. Sickness absence and health in the workplace: understanding employer behaviour and practice. 2021. https://www.gov.uk/government/publications/sickness-absence-and-health-in-the-workplace-understanding-employer-behaviour-and-practice/sickness-absence-and-health-in-the-workplace-understanding-employer-behaviour-and-practice-report (accessed 6 Jul 2022).
10. Department for Work and Pensions, Department for Health and Social Care. Government response: health is everyone’s business. 2021. https://www.gov.uk/government/consultations/health-is-everyones-business-proposals-to-reduce-ill-health-related-job-loss/outcome/government-response-health-is-everyones-business (accessed 6 Jul 2022).