Analysis: Fit notes

On 6 April the Med 3 sick note will be replaced by the new ‘fit note’, or Statement of Fitness for Work recommended in Dame Carol Black’s review of health and work in 2008, and guidance was published last month for GPs.

The fit note differs from its predecessor as it allows GPs to suggest a return to work with adjustments by the employer through the introduction of a new option: “May be fit for work taking account of the following advice”.

The fit note is designed to encourage the doctor to give advice on the functional limitations of the patient’s condition and suggest simple things that might help a return to work. Guidance issued in February to GPs explains the goal of dispelling the mistaken belief that employees have to be completely fit to return to work after sickness absence.

Although the fit note was broadly supported by the 147 respondents to the government’s consultation including employers’ bodies and both occupational health (OH) doctors and nurses’ representatives, early feedback reveals confusion about the legality, practicality and aims of the document among employers, HR and OH practitioners. The fit note’s supporters acknowledge that it will take years to bring about the cultural shift in attitudes needed for the fit note to achieve its aims.

The government’s response to the consultation stated that it had not been possible to “monetise all benefits” – in other words, show costs savings for the NHS and benefits system from improvements in health and reductions in long-term sickness absence. An evaluation will be published in 2012-2013.

The advice for GPs clarifies the respective roles of GP, employer and employee: “What you complete on the statement is advice to your patient and is not binding on their employer. The purpose of the advice you provide is to help your patient and their employer explore ways of facilitating a return to work. In some cases this may not be possible and your patient will be treated as if you had advised that they were not fit for work. In such a situation, patients are not required to return to you for a new statement. Employers’ duties under the Disability Discrimination Act however, remain unaffected and will continue to apply.”

The government’s response to the consultation clarifies what the employer will be expected to do. “In all cases it is the employer’s responsibility to carry out a risk assessment when an employee returns to work to ensure there is minimal risk to the employee and others in the workplace,” it says. It adds: “It is not the doctor, but the employer, who is best placed to make the decision as to whether they can accommodate any changes to facilitate a return to work.”

Fit notes: the key changes

• A new option: “May be fit for work taking account of the following advice”.

• A box for GPs to make comments on how a patient’s condition may affect their capacity to function at work and suggest simple adjustments.

• The maximum duration in which a medical statement can be issued will be three months during the first six months of a patient’s health condition.

• A fit note can be issued on the basis of a telephone consultation or report from other healthcare professionals.

However, some OH nurse advisers are sceptical about the willingness of GPs to change their practice. Catherine Keyes, OH manager (safety, health and environment) at BAE Systems, writes in this issue (March 2010): “The [government’s] response states that “doctors completing the medical statements do not have the knowledge or expertise about an individual’s job role and the risks involved” to enable them to make this judgement. If this argument is valid, how can the GP make the judgements ‘unfit for work’ or ‘may be fit for some work’?”

On the other hand, Dr Mark Simpson, medical director of Axa Icas Wellbeing, is confident that GPs will embrace the new approach. “By and large absence certification is more the employee’s view of their fitness to return for work than the GP’s view, and very rarely will a GP say to an employee who wants to go back to work that you shouldn’t do so,” he says.

Dr Paul Nicholson, associate medical director of Proctor & Gamble UK, says GPs have the competence to offer return-to-work advice. “In many cases the advice is quite simple – [for example] if somebody’s rehabilitating after a hysterectomy or coronary artery bypass and in an office job, it makes sense that they return to work gradually over the next three weeks, four weeks, or whatever,” says Nicholson.

OH practitioners are disappointed that the government decided against including a tick box allowing GPs to refer patients to an OH specialist. The government’s justification is that they are not currently widely available in primary care, and that the box would become an easy default option for GPs. However, GPs can indicate that an OH referral would be beneficial if the issues are more complex and there may be a work-related cause of the condition.

Nicholson says the decision against the OH referral option is a “potential missed opportunity”. “It would have raised awareness of that lack of access and might have made important changes in the future in terms of improving access to OH.”

Meanwhile, employment law experts are predicting conflict at work – for example, when an employee refuses to return to work even after adjustments are made and the employer must decide whether or not to dismiss the individual or stop paying statutory sick pay.”

We can expect more awkward issues to be raised over the coming months, but there is broad agreement that the aims of the fit note can only be a good thing.


  • Reforming the Medical Statement – Government response to the consultation on draft regulations: The Social Security (Medical Evidence) and the Statutory Sick Pay (Medical Evidence) (Amendment) Regulations 2010. January 2010.



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