What drives the ‘sick note culture’ in the UK?

Nada Khan is an Exeter-based GP and clinical academic, and an Associate Editor at the BJGP.

Does Britain have a problem with excessive sickness absence and a lazy workforce?  The Prime Minister, Rishi Sunak, seems to think so.  He cites a national ‘sick note culture’ and ‘floodgates’ of people being written off work, announcing a review of the fit note system to reduce the number of people being written off work.¹  Given that use of long-term sickness certification falls within the remit of general practice, what is the history behind the use of fit notes and what are the potential changes afoot?

Are GPs ‘dishing out’ fit notes without a proper patient assessment? 

As sickness certification is regularly part of a GP’s practice, GPs are often seen as gatekeepers to sick leave.  This role means that GPs are in the firing line of efforts to reduce sickness certification. In his speech, Rishi Sunak suggested that the responsibility for issuing fit notes could be moved from GPs to specialist occupational health professionals to assess an individual’s ability to work and offer support on a tailored basis.¹

The current iteration of the fit note was developed to move away from a just a ‘sick note’ and to allow clinicians to highlight where individuals may be able to return to work with adjustments, with the aim of reducing unnecessary sickness absences and improving return to work rates. After it was introduced, GPs acknowledged that the move toward a ‘fit note’ was a positive approach to empower patients to return to work. GPs generally saw this as good for their patients’ health.²

Some GPs, however, focus on their role as patient advocate and shy away from their role as ‘gatekeeper’ to sickness certification to avoid conflict with their patients.³  Most GPs will not refuse to sign someone off work, but may negotiate with patients to issue shorter fit notes, or engage patients in setting targets for a return to work.⁴  The proportion of patients given a ‘may be fit’ for work recommendation hovers around 6.5% in general practice, and tackling the high proportion of people signed off as ‘not fit to work’ is certainly part of the current government’s motivation for announcing this fit note review.⁵

What happens in practice?

It’s worth remembering that the advice given on the fit note is guidance and is not legally binding on an employer.  Previous research has suggested that the low proportion of people getting a ‘may be fit’ recommendation is a result of poor communication between employees, GPs and employers.⁴  Employers can be a major obstacle to people getting back to work.  Although GPs may recommend amendments or adjustments to work, or work hours, employers aren’t always able to accommodate these and a note from a GP isn’t always enough to change that.²  If someone is certified as potentially fit for work with amendments to their job, but the employer cannot reach an agreement on how to support them with these amendments, that person will continue to be treated as unfit for work, a result that can lead to frustration amongst both GPs and their patients who can see potential solutions for a return to work.  Even where GPs are using the fit note to suggest amendments to work, these adjustments are not always being made, and it’s unclear how a specialist service might be able to change this.

GPs do agree that one short consultation is not always enough to understand a person’s job or their employer’s capacity to support amendments, or to properly engage with providing detailed occupational health advice.⁴  And this is all within the context of GPs feeling that they’ve reached their limits in experience and knowledge in specialist occupational health and understanding the work environment of their patients’ employment.  It’s interesting that GPs with a Diploma in Occupational Medicine were more likely to recommend that the patient group that they saw ‘may be fit’ for work, with a higher proportion providing structured advice for work, though these GPs may be seeing a very select group of patients.⁵  It’s possible that having more time for assessing patients on long-term sick leave alongside more training, could empower GPs and patients to have more productive discussions about what could get them back to work, employer permitting.

Have we been here before?

Back in 2008, Dame Carol Black’s review which initially recommended use of the Fit Note also recommended developing a Fit for Work service based on a case-by-case multidisciplinary approach to provide advice and support for people on, or entering long-term sickness absence of four weeks or more.⁶  The programme was not a success.  A process evaluation of the Fit for Work service found that a substantial proportion of those people referred to the service didn’t take it up.  The majority of referrals came from employers and not from GPs, which contributed to low referral rates and the eventual closure of the Fit for Work service in 2018.⁷

This time around, the back to work service announced by the Prime Minister is called ‘WorkWell’, and aims to provide a ‘single, joined-up assessment and gateway into local employment support services to help people manage their health conditions and get back to work sooner’.  The WorkWell pilots are underway, with funding available to organisations to apply for, design and deliver a WorkWell service. The current government hopes that the WorkWell pilots will also trial new ways to reform the fit note process and move sickness certification away from GPs.  The plan is to offer £57 million of funding to run these pilots in 15 areas from 2024 to 2026.

If this government, or the next one, decides to continue with the WorkWell pilots, they would do well to think very carefully about what worked and what didn’t work with the Fit for Work service, and ensure that any bidders have addressed the failures of previous services.  In any case, WorkWell is not going to be a quick fix.  The Fit for Work service, which was suggested in the Black review in 2008, had a piloting phase, followed by that process evaluation, and was eventually ditched in 2018.  Dr Kathryn McKinnon, chair of the British Medical Association’s Occupational Medicine Committee, voiced her concerns around the WorkWell service stating that ‘we need to see the details on how it will be implemented, this seems like an announcement made out of nowhere with no thought or reasoning into how huge this could be to occupational health’.⁸

The future of the fit note and the roots of the problem

The Prime Minister wants us to be ‘more honest about the risk of over-medicalising the everyday challenges and worries of life’.¹  As the Prime Minister noted in his announcement of the Fit Note review, long-term sickness is being driven in part by mental health conditions.  It does seem that the ‘everyday challenges and worries of life’ are intertwined with in everyday experiences of facing the increasing cost of living and long waiting lists for specialist secondary care treatments for mental health and musculoskeletal services, the two clinical areas that drive the majority of sickness certification.  With an election looming, it’s possible that the government is trying to gain traction amongst the electorate by appealing to the public on a topic that may garner votes.  The current government may do well to reflect upon the trail of causation here.  Much of the problem may not revolve around how GPs are issuing fit notes and suggesting that patients aren’t fit for work. Where does the responsibility lie for the root causes of why people are going off sick in the first place or are unable to access services to deal with those illnesses?  Not even the best occupational health service can fix that. It is time to reframe the problem in order to build the right solution.

Deputy Editor’s note: see also – https://bjgplife.com/could-new-changes-to-the-fit-note-be-an-opportunity-for-primary-care/ and https://bjgplife.com/why-gps-must-not-lose-their-role-in-supporting-people-back-to-work/

References

1. PM to overhaul benefits system and tackle Britain’s “sick note culture” in welfare reform speech Prime Minister’s Office, 10 Downing Street2024 [Available from: https://www.gov.uk/government/news/pm-to-overhaul-benefits-system-and-tackle-britains-sick-note-culture-in-welfare-reform-speech.
2. Welsh VK, Mallen CD, Wynne-Jones G, Jinks C. Exploration of GPs’ views and use of the fit note: a qualitative study in primary care. Br J Gen Pract. 2012;62(598):e363-70.
3. Wheat HC, Barnes RK, Byng R. Practices used for recommending sickness certification by general practitioners: a conversation analytic study of UK primary care consultations. Soc Sci Med. 2015;126:48-58.
4. Wainwright E, Wainwright D, Keogh E, Eccleston C. Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study. Br J Gen Pract. 2011;61(593):e794-800.
5. Dorrington S, Roberts E, Mykletun A, Hatch S, Madan I, Hotopf M. Systematic review of fit note use for workers in the UK. Occup Environ Med. 2018;75(7):530-9.
6. Black C. Working for a healthier tomorrrow. London; 2008.
7. Gloster RM, R.; Huxley, C. Fit for Work: Final Report of a Process Evaluation. Institute for Employment Studies; 2018.Contract No.: Research Report 959.
8. PM should focus on helping patients get care rather than hostile rhetoric on ‘sicknote culture’, says BMA: British Medical Association; 2024 [Available from: https://www.bma.org.uk/bma-media-centre/pm-should-focus-on-helping-patients-get-care-rather-than-hostile-rhetoric-on-sicknote-culture-says-bma.

Featured image by Scott Graham on Unsplash