Simon Smail is a GP and occupational health physician in Edinburgh, and medical director of Evergreen Medical & Wellness Clinic
In July’s BJGP, Dipesh Gopal argues that GPs should no longer certify long-term sickness, citing falling continuity, limited knowledge of workplaces, and the uneasy overlap between clinical care and welfare certification.¹ The Mayfield review has placed the same question into a wider policy context, with proposals for workplace health provision and future fit note reform.² I agree with the direction of travel. The fit note sits poorly in general practice, and I have long thought it belongs elsewhere. The question is not whether it should move, but how, and whether the replacement trades one problem for another.
The difficulty with the GP-issued fit note is twofold. First, the GP is rightly the patient’s advocate. That is central to the therapeutic relationship, but it means the recommendation may understandably align with what the patient feels they need at that moment. That is not always the same as what will best serve their longer-term health, their employer, or their prospects of returning to suitable work. The evidence that good work is generally beneficial for physical and mental health, and that worklessness is associated with poorer health outcomes, is substantial.³ A note written to protect someone from work may sometimes have the unintended effect of protecting them from recovery.
The second problem is more practical. GPs are not routinely trained in occupational health, and we rarely know enough about an individual’s workplace, job demands, safety risks, or possible adjustments we could suggest. We often know the illness but not the work.
Fitness for work is not just an administrative judgement. It requires clinical judgement about diagnosis, prognosis, function, medication, relapse risk, and safety.
An effective return to work usually depends on a conversation between employer, employee, and someone who understands the health condition and the work. The fit note contains little of that. It is a one-way clinical statement, commonly issued without workplace information and without dialogue. That is why it so often fails to bridge the gap it is meant to close. Restoring that three-way interaction, employer, employee, and an occupationally informed professional, is where much of the clinical value of return-to-work planning lies.
The risk in reform is that one bias is replaced by another. Move from a GP who advocates for the patient to a system whose success is judged mainly by reducing economic inactivity, and the pressure can simply reverse: towards work rather than away from it. Neither serves the patient well. A credible model must hold the middle ground: independent, evidence-based, and built around dialogue, not a unilateral and isolated clinical decision.
Working in both general practice and occupational health, I have seen how much this distinction matters. Fitness for work is not just an administrative judgement. It requires clinical judgement about diagnosis, prognosis, function, medication, relapse risk, and safety. Safety-critical work makes this obvious, but the same principle applies whenever a person’s symptoms or treatment could affect whether they can work safely, or whether work is likely to support recovery or worsen their condition. A largely non-clinical service, however well intentioned, will miss some of those lines unless clinical oversight and escalation are designed in from the start. Without them, the system becomes unsafe, and an unsafe system serves neither employer nor employee.
None of this means everyone needs to be referred to occupational health. That would be neither affordable nor necessary. A well-structured service could expand return-to-work and stay-in-work support for the majority, provided it has clear clinical governance, safe triage, and escalation for the cases that need clinical occupational health expertise. The RCGP and Society of Occupational Medicine have both made this point.⁴,⁵ The hard part is not the principle. It is deciding who recognises complexity, and who carries the risk when they are wrong.
Another issue is who pays. The proposed Workplace Health Provision in the Mayfield review is employer-funded, with an estimated cost of £5–£15 per employee per month.² Participation in the Vanguard phase is voluntary and self-funded.² Occupational health is already under-used by smaller employers for one reason above all: cost. Mayfield’s own report notes that access to occupational health varies sharply by employer size.²
…reform will only work if general practice, occupational health, employers, employees, and the new work-and-health structures are designed together.
A voluntary, employer-funded model may therefore work best for the organisations that already have the scale, management capacity, and incentive to engage. Smaller employers may struggle most. If the fit note leaves general practice and nothing affordable replaces it for small and medium-sized employers (SMEs), they could lose their only current, albeit limited, source of work-related clinical input while gaining little practical support.
The answer is not to load workforce health onto employers by legislation alone, least of all onto the smaller ones least able to respond. If this is to work, incentives need to be strong, practical, and monetary rather than punitive. Regional and pooled models, proper clinical governance, and affordable access for SMEs are not optional details; they are the conditions on which reform will stand or fall.
So I support moving long-term fit notes out of general practice. But the reform will only work if general practice, occupational health, employers, employees, and the new work-and-health structures are designed together.
Get it wrong and we reach the worst possible outcome: more workload back on GPs, less clinical expertise for patients, more cost for employers, and no better outcomes for anyone. The opportunity is real. So is the risk of wasting it.
References
- Gopal DP. Should general practice certify long-term sickness? Br J Gen Pract. 2026;76(768):322.DOI: 10.3399/bjgp26X746037
- Mayfield C. Keep Britain Working: Final Report. London: Department for Work and Pensions and Department for Business and Trade; 2025. [accessed 1/8/26]
- Waddell G, Burton AK. Is Work Good for Your Health and Well-being? London: The Stationery Office; 2006. [accessed 1/8/26]
- Royal College of General Practitioners. Position statement on fit notes. London: RCGP; November 2025. [accessed 1/8/26]
- Greenberg N. Society of Occupational Medicine statement on overhaul of fit note system. London: Society of Occupational Medicine; 20 May 2026. [accessed 1/8/26]
Featured image by Scott Graham on Unsplash
