Dipesh Gopal is a GP in North London and National Institute for Health and Care Research School for Primary Care Research Career Development Fellow at Wolfson Institute of Population Health, 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 while others suggest that too little is known about workplaces or ability to work.3 A statement from the Royal College of General Practitioners in response to the BBC investigation alluded to GPs keeping the ability to issue short-term fit notes perhaps up to 3 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 in 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 the ‘five giants’ — poverty, disease, lack of education, poor housing, and unemployment. Sick certificates allowed those in need in a post-war period to access food and materials such as clothing and or even thermos flasks. 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
While relational continuity of care arguably offers insights into a patient’s situation that could inform both welfare eligibility and personalised approaches to rehabilitation, 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
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.
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 and may not value it enough
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 in relation to discrete physical events such as myocardial infarction and fractures. However, the recovery of many conditions, such as low back pain and depression, are poorly defined and often complicated by psychosocial factors. A comprehensive medical recovery service may not even be considered financially viable by policymakers or employers.
4. Sickness certification is not a neutral intervention
Sickness certification is linked increased mortality and morbidity in the UK and internationally. Studies from the UK9,10 and many European countries11 confirm that prolonged sickness absences or high numbers of absences are associated with up to five times all-cause mortality risk compared to those without sickness absences, including those with pre-existing cancer and cardiovascular disease.11
5. Certification of sickness acts a ‘welfare gatekeeping’ role
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.
Certification of sickness gatekeeps welfare. The GP has a conflicting interest by playing roles as a doctor and simultaneously as a government welfare officer.
6. Sickness certification uses several assumptions set in the 20th century5
Twentieth 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 that require employer input before physician sickness certification.12 Within the UK, vocational advisors based in general practice decreased sickness absence and could generate millions of pounds in societal savings.13 There are pending evaluations of pilots of work coaches14 in the community and Jobcentre Plus staff in GP surgeries in the UK.15 More easily accessible occupational health services would be ideal but this is not affordable for small- and medium-size businesses.16 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 a service will involve trained work coaches, social prescribers, and occupational health professionals.4 New pilots will be launched from July this year in consultations where GPs do or do not issue an initial fit note, with an option to refer or automatic referral to this support service.17 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; 12 Mar: https://www.bbc.co.uk/news/articles/c20lew24kngo (accessed 27 May 2026).
2. Salisbury H. Helen Salisbury: the use and misuse of fit notes. BMJ 2026; 392: s501.
3. Anonymous. I’m a GP who knowingly signs healthy people off work. The Telegraph 2026; 19 Mar: https://www.telegraph.co.uk/news/2026/03/19/i-sign-healthy-people-off-work (accessed 27 May 2026).
4. Royal College of General Practitioners. College response to BBC research on fit notes. 2026. https://www.rcgp.org.uk/News/BBC-research-on-fit-notes (accessed 27 May 2026).
5. Millward G. Sick Note: A History of the British Welfare State. Oxford: Oxford University Press, 2022.
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; DOI: https://doi.org/10.3399/BJGP.2020.0935.
7. Kajaria-Montag H, Freeman M. Explaining the erosion of relational care continuity: an empirical analysis of primary care in England. INSEAD Working Paper No. 2020/47/TOM. SSRN 2021; DOI: 10.2139/ssrn.3699385.
8. Massey A. Sick-Note Britain: How Social Problems Became Medical Issues. London: C Hurst & Co Publishers Ltd, 2019.
9. Kivimäki M, Head J, Ferrie JE, et al. Sickness absence as a global measure of health: evidence from mortality in the Whitehall II prospective cohort study. BMJ 2003; 327(7411): 364.
10. Bambra C, Norman P. What is the association between sickness absence, mortality and morbidity? Health Place 2006; 12(4): 728–733.
11. Kivimäki M, Head J, Ferrie JE, et al. Sickness absence as a prognostic marker for common chronic conditions: analysis of mortality in the GAZEL study. Occup Environ Med 2008; 65(12): 820–826.
12. Nordling P, Nwaru C, Nordeman L, et al. 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; 25: e64.
13. Wynne-Jones G, Artus M, Bishop A, et al; 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; 159(1): 128–138.
14. Department for Work and Pensions, Department of Health and Social Care. WorkWell. 2026. https://www.gov.uk/government/publications/workwell (accessed 27 May 2026).
15. 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; DOI: 10.12968/bjhc.2024.0091.
16. Department for Work and Pensions, Department for Business and Trade. Keep Britain working final report. 2026. https://www.gov.uk/government/publications/keep-britain-working-review-final-report/keep-britain-working-final-report (accessed 27 May 2026).
17. Department for Work and Pensions, Department of Health and Social Care. Broken fit note system to be overhauled. 2026. https://www.gov.uk/government/news/broken-fit-note-system-to-be-overhauled (accessed 27 May 2026).
Featured image by Scott Graham on Unsplash.
