A brief history of the fit note

Since its introduction in April, the fit note has been used by GPs with varying success. Ben Hicks summarises the situation.

Reports on how GPs have been using the new “fit note” have varied with some suggesting GPs were simply using it as a sick note and others saying communications between employers and GPs had increased. The Institute for Employment Studies (IES) recently brought together occupational practitioners and GPs to get a snapshot of how the fit note, introduced in April 2010, is faring.

Neil Goulbourne, an inner-city GP covering the Coventry area, supported the fit note and felt it should have been introduced much earlier.

quotemarksThe fit note provides me with one form with more options, allowing me the flexibility and space to provide greater details on a patient’s condition and dates of their predicted absence.”

Dr Neil Goulbourne,
inner-city GP

He says: “Many people I see wish to work and can work, but this wasn’t an option with the old sick note. The fit note provides me with one form with more options, allowing me the flexibility and space to provide greater details on a patient’s condition and dates of their predicted absence.”

Dr Laurence Buckman, chair of the British Medical Association’s (BMA) GP’s Committee, held similar views. “Being in work is good for people’s health and wellbeing. For that reason the BMA is pleased that the sick note system has finally been overhauled. It should reduce the number of forms used and will provide a better way for a GP to give advice about a patient to their employer.”

Kate Owen, an OH adviser for an employer of about 7,000, also supported the fit note. “With the previous sick note there had only been two options – fit for work or unfit for work. With these options, GPs were more inclined to sign the employee unfit for work, when there was a possibility they could carry out some form of work even if it wasn’t necessarily their usual tasks.”

This was echoed by Janet O’Neill, another OH adviser, who believed the fit note was an “excellent tool” that would “make GPs think before ticking the ‘not fit’ box”.

OH professionals saw the fit note as a positive step, but there were differences in their experiences of its practical use, particularly in terms of the advice provided by GPs on “reasonable adjustments”. Some of these initial problems were related to the lack of GP experience with, and training on, the fit note prior to its introduction.

O’Neill described confusion with GPs ticking the box that stated an employee was fit for work following reasonable adjustments but then telling the employee that these should only be brought in at the end of the note’s duration.

“GPs didn’t know how to say that a person could come back to work with adjustments after two weeks of being off. They presumed the end date of the note would be when the adjustments started, but the OH adviser presumed it was from the start date.” Such instances have become less common now GPs are becoming more accustomed to using the new form, O’Neill said.

Tara Stewart, a newly qualified GP in Chichester, said she felt more comfortable issuing the fit note after taking a training course, but recognised that other GPs may not find time for such training. She also noted that “whilst there is an online training course, most GPs will find it hard to make the time to do this”.

Advising on reasonable adjustments

Apart from teething problems, there does seem to be a more fundamental issue about how GPs provide advice concerning reasonable adjustments which may take more time to resolve. Liz Felstead, who heads the OH and Safety division of East Sussex County Council, had concerns about how GPs may respond to what was being asked of them. She says: “GPs would not see it as part of their role and don’t have the OH background or understanding of the employee’s role and duties to make suggestions for reasonable adjustments which could be accommodated by the employer.

quotemarksA number of my early encounters with the fit note showed that GPs either ticked all of the reasonable adjustment boxes without further explanation or, when in doubt, signed people as not fit for work.”

Liz Felstead,
OH and Safety division head,
East Sussex County Council

“A number of my early encounters with the fit note showed that GPs either ticked all of the reasonable adjustment boxes without further explanation or, when in doubt, signed people as not fit for work.”

Other OH and HR professionals agreed, describing ambiguous advice given by GPs, or cases where the GP had just written “refer to OH”. This suggests a lack of knowledge among GPs of an employee’s role or of their workplace, where OH advice is not necessarily available.

Teresa Tojuola, an HR adviser for a central government department, said advice from a GP, although vague, had been beneficial for the organisation. “Before the fit note all employees were sent for a full referral to an OH physician to seek advice and avoid a potential breach of the Disability Discrimination Act. Now, however, for cases where advice has been given by a GP, an employee can be referred for a quick assessment by an OH adviser to discuss reasonable adjustments rather than needing a full assessment from an OH physician. This has saved the department money and also sped up the process for the employee.”

GPs have also found giving advice to an employee who has access to OH facilities an easier process. Goulbourne said, “I’m able to put down advice on reasonable adjustments which is quite broad brush. I tend to stick to the generic recommendations and feel comfortable doing this as many of the patients I see at the surgery have already seen someone from OH at their workplace.”

When the employer does not have an OH department this can be more difficult. Stewart explains that many of her patients are manual labourers and cannot always access OH advice, so she can find it difficult to identify what is a reasonable adjustment for their employers. “I don’t know what manual labour entails as I have no OH training and no OH advice,” she says.

In this instance it would be necessary for a GP to understand the equipment used, and how work is planned. It may be better to go through these aspects of the job with the employer rather than the individual, but GPs are not always able to do this.

Fear of legal consequences

Given GPs’ lack of information about a patient’s employer or feedback on what reasonable adjustments they can incorporate, they can be wary of making more tailored suggestions so they can avoid potential legal claims later on if the patient’s condition worsens. Any suggestions they do make are often based solely on the information their patient provides.

“The advice I give isn’t legally binding, it’s just advice and perhaps the patients and employers don’t realise this and so when they receive a note suggesting shorter hours, they feel obliged to do this,” says Stewart. “I’m wary of legal terms and report writing that may be used later in a serious situation and that is when I would value OH advice.”

Dr Laurence Buckman agrees, saying: “GPs need to be careful they are not drawn into making comments they are not qualified to make. Unlike OH professionals, they are often not in a position to know the details of the patient’s working conditions, neither do they have specialist knowledge of workplace hazards.”

Employer resistance

quotemarksIt feels that often employers don’t want to accommodate advice on what people can do. Perhaps they’re fearful that if further injury occurs then they’ll be held liable. The employer would rather the employee not go in for the duration of the fit note.”

Dr Neil Goulbourne,
inner-city GP

Some GPs have found that employers are less than willing to adapt to the new system. Goulbourne felt that “employers don’t seem keen on making adjustments. Everything seems to need to be signed off by OH before the employer will pay for it, which is strange as what’s being advised isn’t complicated.

“It feels that often employers don’t want to accommodate advice on what people can do. Perhaps they’re fearful that if further injury occurs then they’ll be held liable. The employer would rather the employee not go in for the duration of the fit note.”

Another worried GP, Dr Dadabhoy, wrote to Secretary of State for Work and Pensions Iain Duncan Smith in June. The letter voiced concerns that employers “lacked imagination” when trying to implement reasonable adjustments, meaning that employees with initially minor health problems were not being allowed to work, which may have further implications for their long-term outcomes. He also said one of his patients “is upset as although she is willing and able to work, she will have these many weeks recorded as sickness”.

This suggests that even when GPs do make useful suggestions on reasonable adjustments, some employers that may not understand the benefits of an early return to work for employees will not act on them.

What next for the fit note?

The most pressing concerns about the fit note appear to be around the clarity of the reasonable adjustments that employers should be making to accommodate an early return to work. This is not solely due to a lack of OH expertise among GPs, but also their fears about potential legal disputes and lack of training.

Many GPs within their allocated 10-minute consultations with patients have little time to discuss the workplace and reasonable adjustments and are wary of making suggestions solely on information from the patient. Having advice on hand on what reasonable adjustments an employer can accommodate, or how to contact the OH adviser, would help.

There are sources of support. For example The Royal College of General Practitioners’ website Healthy Working UK offers advice to GPs, and the current Department for Work and Pensions OH helpline offers free telephone support from an OH nurse for employers and GPs. However, GPs may not have the time to access these due to heavy workloads.

More open communication between OH professionals, employers and GPs is vital. Some proactive OH professionals are taking steps to work with GPs so that they become familiar with the main employers in their area, and therefore feel more comfortable in what constitutes a reasonable adjustment, having a better understanding of the nature of the workforce, jobs and the circumstances of the employer.

quotemarksThe fit note will mean OH professionals have far greater interaction with GPs in order to aid an earlier, supported, return to work for individuals where possible. This does, however need to be led by OH for it to be effective as GPs are their patient’s advocate.”

Janet O’Neill,
OH adviser

O’Neill summarises the way that OH and the GP can work together to enhance the benefits of the fit note: “The fit note will mean OH professionals have far greater interaction with GPs in order to aid an earlier, supported, return to work for individuals where possible. This does, however need to be led by OH for it to be effective as GPs are their patient’s advocate.

“GPs appear more willing to talk and listen to OH since the advent of the fit note. In the long term this will close the rift between OH and GPs, and supported return to work is likely to be seen as part of the therapeutic process. At present it appears difficult for GPs to match possible adjustments to the individual’s role unless initiated by their patient and this is what I aim to change by providing information to the GP with employee consent.”

In smaller organisations where OH is not available it is even more important that a relationship is built up between GPs and their local employers; but employers need to take the lead. The GPs agreed that they would value receiving a summary from an employer of the daily duties an employee carries out within the organisation. They also felt that it would be beneficial to receive the line manager’s contact details, and the employer’s initial thoughts about what adjustments might be possible. Employees could bring these to the surgery.

By developing these mutual open relationships, GPs can promote the benefits of an employee’s early return to work to the employer and can also discuss more imaginative return-to-work adjustments that can be accommodated within the organisation.

The fit note has great potential, but there is still some way to go before this is fully realised. Communication between GPs, OH, HR and employers is vital in ensuring clear recommendations are provided to employers, and most importantly that these recommendations are effectively taken forward.

This article is based on an IES HR Networking event held on May 25th 2010. For more information email Ben Hicks.

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