Should general practice certify long-term sickness?

Dipesh Gopal is a GP in North London and NIHR School for Primary Care Research (SPCR) Career Development Fellow at Queen Mary University of London. Connect with him on social media: https://linktr.ee/dipeshgopal.

This March saw the BBC report that 72% of 752 surveyed GPs had never refused to sign a fit note due a mental health illness.¹ As a result, there has been debate about whether GPs should continue to issue fit notes: some argue that compassionate circumstances² such as challenging working conditions are grounds for issue whilst others suggest that too little is known about workplaces or ability to work.³ A RCGP statement in response to the BBC investigation alluded to GPs keeping the ability to issue short-term fit notes perhaps up to three weeks.⁴ In contrast for longer sickness certification, GPs would be part of multidisciplinary team including occupational health rather than primary arbiters.

Sickness certification has changed a great deal since its inception. In the early 1900’s sickness was paid by ‘friendly societies’ and trade unions and certified by doctors but this changed with 1948 after the birth of the welfare state where the government footed the cost.⁵ This was part of William Beveridge’s dream to tackle 5 giants – poverty, disease, lack of education, poor housing and unemployment. Sick certificates allowed people in a post war period to access food, and materials such as clothing and or even thermos flasks for those in need. A lot has changed since 1948, and I argue that doctors and especially GPs should no longer certify long-term sickness for the following reasons:

1) Continuity of care is dropping in the UK

Whilst relational continuity of care is linked to lower risk of death, better patient satisfaction, less hospitalisation and emergency department use, continuity of care is dropping in the UK.⁶ This is likely due to changing work patterns, higher dependence on temporary staff in practice and high patient demand without a supporting increase in workforce capacity.⁷

2) Certifying sickness is not the same as assessing work capacity⁸

A clinician’s job is to identify symptoms that fit a diagnosis to determine a treatment plan. However, this is not the same as determining whether someone can work. We don’t receive the right training to identify working conditions, the nature of work, or safety in the workplace to determine work capacity.

3) We don’t understand recovery

Our definition of illness is growing but our understanding of recovery has not kept pace. There is clear guidance on recovery and fitness to drive on discrete physical events such as myocardial infarction and fractures. However, as Schön describes the ‘swampy lowlands’ of general practice are complex and hard to define there is no guidance for conditions such as depression, grief and low back pain.

4) Sickness certification is not a neutral intervention.

Sickness certification is linked increased mortality and morbidity in the UK and internationally. Studies from the UK,^9,10 Sweden,^11,12 Norway,¹³ Finland,¹⁴ and France¹⁵ confirm that prolonged sickness absences or high numbers of absences are associated with up to 5 times all-cause mortality risk compared to those without sickness absences. Those with pre-existing cancer and cardiovascular disease with sickness absences have 4 to 5 times-fold increased mortality risk compared to those without pre-existing conditions.^14,15

5) Certification of sickness acts a ‘welfare gatekeeping’ role

Certification of sickness gatekeeps welfare. The GP has a conflicting interest by playing roles as a doctor and simultaneously as a government welfare officer.

5) Sickness certification uses several assumptions set in the 20th century⁵ which are no longer valid for the 21st century.

20th century ‘assumptions’ include single breadwinner family incomes, secure jobs for life with single companies, strong relationships with family doctors and jobs for everyone backed by a robust industrial strategy.

Today, pushback against sickness certification for individual patients is difficult and risks complaints even when justified. We must advocate for a better system such as Swedish capacity notes which require employer input before physician sickness certification.¹⁶ Within the UK, vocational advisors based in general practice decreased sickness absence and could generate millions of pounds in societal savings.¹⁷ There are pending evaluations of pilots of work coaches¹⁸ in the community and Jobcentre Plus staff in GP surgeries in the UK.¹⁹ More easily accessible occupational health services would be ideal but this is not affordable for small and medium businesses.²⁰ There is UK government appetite to change the current welfare system and create a working standard, data unit and non-clinical service to improve the status quo. Such changes could involve trained work coaches, social prescribers and occupational health professionals with access to referrals to GPs where appropriate.⁴ All of these may be more appropriate than GPs continuing to certify long-term sickness.

Deputy editor’s note – see also debate on the phenomenon by some of our regular contributors:

• https://bjgplife.com/what-drives-the-sick-note-culture-in-the-uk/
• https://bjgplife.com/sick-notes-and-culture/
• https://bjgplife.com/normal-worries-or-mental-illness-sick-note-culture/
• https://bjgplife.com/book-review-recovery-by-gavin-francis/

References

1. Burns C. Hundreds of GPs tell BBC they have never refused a fit note for mental health concerns. BBC News; 2026. https://www.bbc.co.uk/news/articles/c20lew24kngo [accessed 10 April 2026]
2. Salisbury H. Helen Salisbury: The use and misuse of fit notes. BMJ. 2026 Mar 17;392:s501.
3. Lytton C. I’m a GP who knowingly signs healthy people off work. The Telegraph; 2026. https://www.telegraph.co.uk/news/2026/03/19/i-sign-healthy-people-off-work/ [accessed 10 April 2026]
4. College response to BBC research on fit notes. Royal College of General Practitioners; 2026. https://www.rcgp.org.uk/News/BBC-research-on-fit-notes [accessed 10 April 2026]
5. Millward G. Sick Note: A History of the British Welfare State. 2022. Oxford: Oxford University Press.
6. Tammes P, Morris RW, Murphy M, Salisbury C. Is continuity of primary care declining in England? Practice-level longitudinal study from 2012 to 2017. Br J Gen Pract. 2021 May 27;71(707):e432-e440.
7. Kajaria-Montag H, Freeman M. Explaining the erosion of relational care continuity: an empirical analysis of primary care in England; 2020 INSEAD, accessed. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3699385. 8 Jul 2025
8. Massey A. Sick-Note Britain: How Social Problems Became Medical Issues. 2019. London: C Hurst & Co Publishers Ltd.
9. Kivimäki M, Head J, Ferrie JE, Shipley MJ, Vahtera J, Marmot MG. Sickness absence as a global measure of health: evidence from mortality in the Whitehall II prospective cohort study. BMJ. 2003 Aug 16;327(7411):364.
10. Bambra C, Norman P. What is the association between sickness absence, mortality and morbidity? Health Place. 2006 Dec;12(4):728-33.
11. Narusyte J, Ropponen A, Alexanderson K, Svedberg P. The role of familial factors in the associations between sickness absence and disability pension or mortality. Eur J Public Health. 2014 Feb;24(1):106-10.
12. Helgesson M, Johansson B, Nordqvist T, Lundberg I, Vingård E. Sickness absence at a young age and later sickness absence, disability pension, death, unemployment and income in native Swedes and immigrants. Eur J Public Health. 2015 Aug;25(4):688-92.
13. Gjesdal S, Ringdal PR, Haug K, Maeland JG, Vollset SE, Alexanderson K. Mortality after long-term sickness absence: prospective cohort study. Eur J Public Health. 2008 Oct;18(5):517-21.
14. Vahtera J, Pentti J, Kivimäki M. Sickness absence as a predictor of mortality among male and female employees. J Epidemiol Community Health. 2004 Apr;58(4):321-6.
15. Kivimäki M, Head J, Ferrie JE, Singh-Manoux A, Westerlund H, Vahtera J, Leclerc A, Melchior M, Chevalier A, Alexanderson K, Zins M, Goldberg M. Sickness absence as a prognostic marker for common chronic conditions: analysis of mortality in the GAZEL study. Occup Environ Med. 2008 Dec;65(12):820-6.
16. Nordling P, Nwaru C, Nordeman L, Skoglund I, Larsson MEH, Björkelund C, Hensing G. Early structured communication between general practitioner, sick-listed patient, and employer: Results and lessons learned from a pragmatic trial in the Capacity Note project. Prim Health Care Res Dev. 2024 Nov 28;25:e64.
17. Wynne-Jones G, Artus M, Bishop A, Lawton SA, Lewis M, Jowett S, Kigozi J, Main C, Sowden G, Wathall S, Burton AK, van der Windt DA, Hay EM, Foster NE; SWAP Study Team. Effectiveness and costs of a vocational advice service to improve work outcomes in patients with musculoskeletal pain in primary care: a cluster randomised trial (SWAP trial ISRCTN 52269669). Pain. 2018 Jan;159(1):128-138.
18. UK Government. Workwell; 2024. Available from: https://www.gov.uk/government/publications/workwell [accessed 10 April 2026]
19. Pattani S, Varghese K, Shemtob L, El-Osta A. Back-to-work initiatives in primary care: lessons for the future of work and health. Br. J. Health Care Manag. 2024 30:12, 1-3
20. Mayfield C. Keep Britain Working Final Report. UK Government; 2025. Available from: https://www.gov.uk/government/publications/keep-britain-working-review-final-report/keep-britain-working-final-report [accessed 10 April 2026].

Featured image by Scott Graham on Unsplash