Are fit notes really the antidote to absence?

Dame Carol Black and her advisers suggest the ‘fit note’ – due to be launched next month and giving a key role to GPs – will be a solution to the UK’s absence problems. This fails to recognise that the GP is primarily the advocate of the patient, and that this relationship must be preserved to enable appropriate treatment.

GP resistance

Informal feedback from GPs indicates a lack of desire to compromise this relationship by questioning the need for a sicknote when asked for one. It also reveals a lack of desire to police sickness absence on behalf of employers. GPs feel they lack the ability or time to define rehabilitation programmes for employers, especially when no understanding exists about the abilities or willingness of the employer to provide such a programme, or to the detailed duties undertaken by the patient, or the environment where these could reasonably be expected to be carried out.

Most sicknotes are requested by the patient. The advocate’s response, while perhaps accompanied by advice from a motivated or OH-trained GP, would be to make this provision. It is very rare indeed that a GP would insist on the total refrain from any daily activity, and this includes work.

Government response

The government published its response to the extensive consultation surrounding the reform of the medical statement in January. Much further expense will be spent on training for GPs.

The government sees benefits “for individuals, employers, the government and the economy as a whole”. But trade union body the TUC raises concerns about GPs’ ability to provide sufficient advice.

The government response states: “Doctors do not need to have comprehensive knowledge or understanding of an individual’s job role or need any special occupational health expertise. Suggestions made by the doctor will be based on the patient’s health condition and not job-specific.”

Many would question the value of this for the employer, who primarily wishes to ask whether the employee is fit to undertake their normal duties, and frequently wishes to understand whether the job is causing or aggravating a health condition. Non job-specific advice is unlikely to be helpful. The OH professional would always offer the advice in relation to the job and/or working environment.

A further concern with this approach would be that, without the GP and possibly the patient being aware of it, a statement provided without underlying OH expertise could compromise an employee’s employment opportunities. OH professionals understand this dilemma and think carefully about the wider view before making a statement which purely relates to a health condition. Indeed, disability discrimination legislation requires employers to do so, and the OH professional provides information which assists with these legal obligations.

The government’s decision to omit an OH tick-box to allow for an OH assessment – because it didn’t want GPs to view it as a default option – is not easy to comprehend. The frequent use of such an option, were it to be available, would have supported the anecdotal GP opinion previously noted, or an inability to provide this advice with confidence.

The most incomprehensible response to the consultation relates to ‘fit for work’ statements. The 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 make this judgement. So how can GPs make the judgements “unfit for work”, or “may be fit for some work”?


The only way to make significant progress in this area is for employers to take responsibility for the problem. They must establish the means of gaining detailed information about their own situation. This must be followed by the development of an agreed policy and effective communication relating to it to all employees. This action would help to confirm expectations and begin to generate a shift in culture.

Employers might seek to obtain some advice on strategic health planning from a competent OH professional, who might also be a doctor or a nurse, and might already be in-house.

Senior management must expect line management to deliver their responsibilities, and this should include an agreed form of return-to-work discussion for all absences.

OH role

OH professionals can significantly support all parties in relation to long-term sickness absence of more than three weeks. Unlike GPs, in-house OH professionals should already have an understanding of normal working practices and environments and the necessary interpersonal relationships with line-management to facilitate individual rehabilitation programmes which optimise the timing of a return to work without needing a sicknote, fit note, ‘not-really-sure’ note, or a report.

There may be some OH nurses who have been working in organisations that wanted little more than the traditional ‘industrial nurse’. These OH nurses may not be willing or able to offer more currently, but many could be developed to become significant players in supporting their organisations’ strategic health strategy.

Perhaps OH professionals are where they are, in Black’s view, because although one can define the remit of an OH service, the delivery is defined by each individual organisation. Diversity of services and the ability to flex and change at a moment’s notice to support business needs is what makes this a challenging place to be.

Policy-makers, educationalists and government officials appear to have plenty of time to deliberate on how we could be ‘led’ more effectively. Those of us in the field have strong allegiances to our organisations, most of us are as committed as those who are more vocal, but we have a lot to deliver and we just get on with the job.

By Catherine Keyes (pictured left),OH manager (safety, health & environment), BAE Systems. These are the personal views of Catherine Keyes.

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