Fit for work? Changing fit note practice among GPs

INTRODUCTION

The Statement for Fitness for Work (or ‘fit note’) was introduced by the Department for Work and Pensions in April 2010 to replace the medical statement (Med 3 and Med 5), which had been in use since 1948. Rather than simply stating that the patient is unfit for work and assessing how long he or she should remain absent, the fit note provides the GP with an additional option of stating that the patient is fit for work if certain adjustments are made.

The rationale for this change was put forward in Dame Carol Black’s review of the health of the working population.¹ The Black review identified that one barrier to a healthy working population is the assumption that illness is incompatible with work and that work impedes recovery. The review recommended the introduction of a new fit note, which would focus on what people can do rather than what they can’t. This should prevent individuals from moving into long-term sickness absence and reduce the migration of people from work onto benefits.

The research evidence concerning the role of work in health is clear — well-designed and well-managed work is good for health, and can play an important part in recovery. However, research evidence alone is not sufficient to change practice.^2,3 Bringing about evidence-based change in practice is influenced by a number of factors, including the nature of the change, the practitioners adopting it, and the environment they work in.⁴

This article describes the evidence behind the introduction of the fit note, considers some of the implementation issues that have been reported since its introduction, and discusses ways to further embed the change in GP practice.

THE BACKGROUND TO THE FIT NOTE

The health benefits of work

The evidence showing that worklessness is harmful to health, and how maintaining someone in employment can be good for their recovery, is now well developed.^1,5 While some research could be criticised for failing to establish the direction causality, increasingly sophisticated methods have strengthened the causal conclusion that unemployment leads to a decline in health.⁶

Being in work clearly improves an individual’s economic wellbeing, providing them with a higher standard of living and more opportunities for social inclusion. But it also improves their physical and mental wellbeing.

It has been shown that employed people have better health outcomes than unemployed people, with a decreased rate of long-term illness, mental illness, cardiovascular disease, hospital admissions, and mortality.^5,7-10 Employment also brings many psychological benefits, such as social identity and status, a sense of collective purpose, social contact, regular activity, and time structure.¹¹ When people become unemployed these benefits are lost and their physical and mental health will tend to deteriorate.^12-18 Unemployment is also associated with an increased risk of suicide and parasuicide.^19,20

Despite this general picture that work is good for health, work may also cause poor physical and psychological health in some circumstances.^5,21 The beneficial health effects of work are dependent on the nature of the job in question.

Important factors in job retention

Not only are the health benefits of work lost to those who are unemployed, but they will also diminish when someone is absent from work for long periods due to illness. The longer someone is absent from work, the greater the likelihood that they will never return to work.²² One of the reasons for this is loss of confidence, which is exacerbated during a long period of absence from work. The most frequently cited barrier to returning to work after a period of ill-health is anxiety about going back.²³ In contrast, very few employees cite their medical condition, or their ability to manage their illness at work, as a barrier to returning to work.²³

One of the key factors in successfully retaining employment and returning to work after an illness is maintaining contact with and involvement in work during the illness.²⁴ This can help prevent the loss of confidence and anxiety experienced by many people prior to their return to work. Another important factor in achieving job retention is making adjustments to duties, hours, and the workplace to facilitate a prompt return.^25,26 This can allow an employee to return as early as possible, and often before they are back to full capacity.²⁷

The role of GPs in job retention

GPs and other healthcare professionals have a vital role in supporting the health of working people, and in enabling them to stay in or return to work. National Institute for Health and Clinical Excellence (NICE) guidelines on managing long-term sickness absence and incapacity for work state that GPs should balance the immediate health benefits of prescribing time away from work with the potential long-term disadvantages for the patient.²⁸ The GP is usually the first health professional to see a patient who is absent from work due to ill-health, and issues around 20 sickness certificates per week.²⁹ The advice received from the GP can have an impact on whether a person is absent from work, for how long, and whether they take steps to return to work.³⁰ GPs can help to prevent their patient’s absence from work from developing into joblessness, by the following actions:

• emphasising to the patient the potential role of work in recovery;

• discussing with a patient what his/her job involves;

• recommending possible adjustments to his/her work to enable a prompt return to work;

• using the fit note to advise employers of recommended adjustments; and

• referring the patient on to specialist healthcare or employment services (for example, improving access to psychological therapies [IAPT] employment services, and fit for work services).

Clearly, there are challenges for training GPs in performing these functions, such as gaining sufficient insight into the patient’s work role, and persuading both the employee and employer to engage in discussions about workplace adjustments.

The fit note as an improved tool to support job retention

The Med 3 sick note was widely seen as needing improvement, and was unpopular with GPs, occupational health professionals, and employers alike. Its focus was on the cause of the illness, rather than its consequences, and whether the patient was able to do all aspects of their job, rather than just some.^31,32 The context of work and health has changed dramatically in recent years, with health and safety law and equality legislation placing on employers a duty of care that should ensure that workplace adjustments and fair treatment are applied. Changing organisational cultures have also seen increasing levels of flexibility and management support in the workplace for employees, although large variations are still present. A change to the sickness-certification process that is more aligned to employment practices was long overdue.

The fit note provides a prompt for the GP to assess the functional effects of the patient’s condition, to evaluate whether the patient could return to work if certain adjustments were made, and provides more space to encourage further detailed discussion between the patient and their employer. The fit note also removes the requirement for the GP to see and examine the patient, and allows a judgment based on telephone consultation, advice from a colleague, or correspondence from a healthcare provider (for example, a hospital letter, or discharge notification).

The advice provided by the GP on the fit note can be used by the patient as evidence of eligibility for sick pay or social security benefit, or for discussions with their employer about possible workplace adjustments. Although employers are often keen to receive medical advice, they are not obliged to follow a GP’s advice on the fit note. The effectiveness of the fit note in supporting job retention is largely dependent on the employer responding appropriately to the advice given on it by the GP.

IS THE FIT NOTE WORKING?

Early evaluations of the fit note

Early evaluations of pilot studies of the fit note found that GPs were less likely to advise that patients refrain from working, and provided more written advice on fitness to work when using the fit note compared to when using the Med 3 sick note.³³ However, advice from GPs varied considerably with the type of health condition the patient was presenting with. As with other studies, patients with mental health conditions were less likely to be assessed as fit for work compared to those with a physical condition.^29,34-36

The introduction of the fit note has been greeted favourably by most GPs. A recent survey of 1405 GPs in autumn 2010 reported that 61% felt that the fit note had improved the quality of their discussions with patients about return to work, and 70% believed that the fit note had helped their patients make a phased return to work.³⁷ However, how the fit note is being used in practice is less clear.

Commonly-reported difficulties

It is known that there is a large variation in the practice of sickness certification by GPs,³⁸ and GPs’ decisions about sickness certification are often inconsistent.³⁹ Initial reports have already identified some teething problems with the fit note. Concerns have been raised about difficulties in making recommendations about reasonable adjustments, fears about possible legal consequences of the advice GPs give, and also resistance from some employers in utilising the advice given by GPs.^40,41 There are also concerns about the conflict experienced by GPs between their role in patient advocacy and sickness certification. Some GPs report that they routinely agree to patients’ demands for a sickness certificate to avoid conflict,⁴² while GPs who have had occupational health training find that they are better able to assess their patient’s fitness to work and also issue fewer certificates.⁴²

One of the main implications of the fit note for GPs is the need to spend more time with their patient to find out what their work involves and what workplace adjustments may be possible.⁴³ During this process, the GP is completely reliant on what the patient tells him or her about their working environment and practices, and neither GP nor patient are likely to know what adjustments are possible or reasonable from the employer’s perspective. How GPs make their assessments of fitness to work, what information they use in coming to their decisions, how accurate they are, and how employers use the recommendations made on the fit note are key questions for evaluation.

In organisations with rehabilitation and return-to-work policies and a well-developed culture of supportive line management, the fit note is largely received as a useful piece of advice and a basis for discussions about work adjustments. Where the workplace adjustments are not considered as part of the line-management role, the fit note may ignored or even become a source of conflict between the line manager and the employee. While GPs regularly report that employers fail to act on the advice given in fit notes, employers often complain that GPs fail to use the fit note to provide sufficient advice. For example, of the organisations surveyed in the latest absence and workplace health survey, 71% were not confident GPs were using the fit notes any differently from sick notes.⁴⁴ It seems that the fit note itself has not led to improvements in communication and cooperation between GPs and employers.

Myths about sickness certification include:

• GP sickness certification is mandatory for all absence;

• an employer has to accept the advice on a fit note; and

• an employee needs a fit note to allow a return to work.

Although none of these are true, many patients and employers still behave as if they are, and this can lead to frustration for GPs.

BRINGING ABOUT MORE RAPID CHANGE IN PRACTICE

The change in GP practice that the fit note was intended to bring about seems to have started, slowly. But given what we know about the challenges to changing embedded practices,^45,46 the slow pace of change was to be expected. A growing number of resources is available to GPs to support the consistent and effective use of the fit note, including policy leaflets,⁴⁷ training courses, practitioner articles,⁴⁸ and web-based tools.⁴⁹ A number of further developments, described below, may promote a more rapid change.

The e-fit note

GPs have embraced IT in the UK and can record, prescribe, refer, advise, and even educate themselves during the consultation using the computer, but the fit note still requires pen and paper. However, a note generated from the GP’s computer and given to the patient (as with prescriptions) is planned for early 2012. This will make it easier to monitor and analyse the use of the fit note by GPs and will inevitably lead to changes in practice.

Others signing the fit note

Currently, only doctors can sign fit notes, and traditionally this is the patient’s own GP. Within the current guidelines, there is no reason why an independent doctor, working in an impartial role rather than that of advocacy, incumbent in that of the GP, should sign the notes.

An example comes from the Leicester Fit for Work Service,⁵⁰ where fit notes for the clients using this service are signed by a GP specialising in occupational health at a multidisciplinary meeting held once a week, allowing the team to provide an impartial approach to signing notes. As far as we know, this is the first time that a GP has systematically signed fit notes in a different capacity to that of an advocacy role.

Many believe that other health professionals such as nurses, physiotherapists, or occupational therapists should be able to sign fit notes. In a recent survey,⁵¹ 79% of primary care nurse practitioners were already advising patients on fitness for work, and 83% thought it was feasible for them to take on sickness certification.

A new ‘assessment of fitness for work’ form for use by allied health professionals (AHPs) is currently being developed and trialed by the Allied Health Professions Federation, with support from the Department of Health and Department for Work and Pensions. This will test the principle that AHPs are in a good position to provide fit notes in the future. The Assessment of Fitness for Work form aims to provide a consistent tool for AHPs to advise employees on their fitness for work and how they might be able to return to work as part of their recovery. However, the form cannot be used to provide medical evidence for a claim for state benefits, for which patients will still be required to obtain a fit note from a doctor.

Most GPs report being intimidated into signing sickness certification on some occasions.⁴² There is a growing body of opinion that certification signed by an impartial doctor could improve the overall management of people at risk of long-term sickness absence. The potential contribution of other health professionals to the fit note process has yet to be fully explored, but an important factor will be whether patients and employers accept the advice of these professionals.

Patient requests for advice

Patients also have an important role in influencing how GPs use the fit note. Resistance from patients is one of the key factors inhibiting change in the practice and behaviour of GPs.⁵² In a recent survey, 77% of GPs agreed that they ‘feel obliged to give sickness certificates for reasons that are not strictly medical’.³⁷ Patients still visit their GP to be signed off work, rather than to receive a fit note. If, however, patients went into a GP consultation requesting a fit note advising on workplace adjustments, then it is more likely that GPs would oblige. A crucial step not yet considered is better promotion of the fit note, and, more generally, the belief that working can be good for recovery, among patients.

SUMMARY

The introduction of the fit note has been broadly welcomed by GPs and employers as a way of supporting the return to work and job retention of individuals who experience health problems. During the early stages of its implementation, we would expect some difficulties, uncertainties, and a wide variation in the use of the fit note. In the meantime, supporting both GPs and employers in using the fit note effectively must be a priority. Additional support may be effectively provided through local employment retention and rehabilitation services, such as ‘fit for work’ services and IAPT employment advisers. Ensuring that GPs, employers, and patients are aware of these services and able to refer to them would further promote job retention and return to work. The introduction of the e-fit note, the involvement of other health professionals in the fit note process, and improved awareness in patients of the fit note will contribute to a more rapid change in practice. Further debate and discussion about who should be able to sign fit notes and how the use of fit notes is monitored should be encouraged.

Provenance

Freely submitted; externally peer reviewed.