Work and health: Making fit notes work for everyone

Fit notes in practice

The fit note introduced optional advice that the general practitioner (GP) or hospital doctor could give to employers, stating that the individual ‘may be fit for work taking account of the following advice’, with check boxes for the doctor to use to suggest a phased return to work, amended duties, altered hours or workplace adaptations. The doctor could add additional written comments. As of July 2022, medical professionals such as nurses, occupational therapists, and so on, are also able to certify the fit note. This is a significant change and one that could mark a major improvement in the utility of fit notes in supporting return to work and job retention.

The problem with the old system was that that it was not working. More than one-third of fit notes are issued for five weeks or longer (NHS Digital, 2021) – yet we know that the longer someone is off work the chances of them returning decreases (Black and Frost, 2011). In addition, fit notes currently issued tend to focus on the ‘not fit’ for work option, rather than the ‘may be fit for work’ section, thus meaning that they are not being used to their full potential.

A broken system

Of the 8.8 million fit notes used by GPs in 2020, 94% advised that the patient was ‘not fit for work’ without suggesting adjustments or advice for the work conducted, even though it could be argued that most patients with common health problems are deemed low risk and suitable for some form of work. The fit note was introduced to allow clinicians to provide their patients with advice on fitness for work and to encourage patients to resume some work as soon as they had recovered sufficiently. Despite this, clinicians do not provide fitness advice on most fit notes and, in 2016, the UK Government reported in a study that ‘the fit note was “not fully achieving what it set out to do”‘ (DWP, 2016).

Primary care should be an ideal environment to influence work-related outcomes for those living with undiagnosed conditions in the community, as it acts as the first point of contact in the healthcare system and the ‘front door’ of the National Health Service (NHS). All GPs can provide simple fitness-for-work advice to their patients to help them return to work and aid their recovery, but many report being inadequately trained in the health and work topic and in the certification of fit notes. Many GPs report that they feel that it is outside of their ‘therapeutic relationship’ to provide work advice. However, there is a general understanding that GPs and other healthcare professionals should  do all of the following:

• play an integral role in providing information and support for patients about work and returning to work;
• agree that work and return to work is an important health outcome for clinical management;
• enable patients to return to work through shared decision making;
• and help patients and employers communicate effectively.

Change is afoot

As of 1 July 2022, nurses, occupational therapists, pharmacists, and physiotherapists can certify fit notes. This change is one of the most significant since the fit note’s inception in 2010 and could support and empower better conversations about work and health. The change will be delivered in general practice and hospital settings.

Although these other healthcare professionals can, in comparison to GPs, spend more time with patients, and have the ability to assess function related to a mental or physical health presentation, they have not traditionally conducted this work-and-health role. They will need training and development to fully understand the relationship between health and work.

We would like to see tailored ‘light touch’ occupational health advice to patients who receive the fit note within primary and hospital care settings, with better use of the ‘may be fit’ for work section, which as we have seen, is often neglected by GPs. A physiotherapist, for example, could advise a patient on safe return to work with low back pain. This advice could also incorporate a referral trigger for those that have access to an Occupational Health professional.

Our research has centred on the training and development needs for physiotherapists who work within primary care, to ensure that they believe that they have sufficient knowledge and skills to carry out this role (Black et al, 2022).

Making fit notes fit for purpose

Health and work advice is needed for all employed people with musculoskeletal and mental health presentations who are at risk of avoidable sickness. Without adequately understanding the individual training and other barriers to delivery of this health and work agenda, the opportunities for physiotherapists, nurses, pharmacists and occupational therapists to use the fit note to promote work-focused conversations will be limited. Addressing these barriers is essential to improve work-participation outcomes for our patients and to help make the fit note fit for purpose.