Are GPs the right professionals to rule on fitness to work?

Even before Dame Carol Black’s Review of the Health of the Working Age Population was published, health minister Alan Johnson had already raised the subject of sicknotes. He talked about creating a ‘well note’ culture, concentrating on an individual’s capabilities.

Not surprisingly, there was a flurry of debate among GPs about how much more work this would entail, what the practical changes to the certification system might be, and – most importantly – whether they actually have the competencies to judge a patients’ capabilities in any particular work situation. They don’t know the workplace, don’t understand the nature of the tasks in the patient’s job, and don’t understand the hazards and risks. “Isn’t this the job of occupational health professionals?” they ask.

Impact of guidance

What do we know about the present sicknote system? The purpose of a Med 3 or Med 5 is to certify eligibility for state benefits. There are detailed rules about medical certification on the HM Revenue & Customs website,1 and extensive guidance from the Department for Work and Pensions (DWP).2 It has produced desktop guides on certification for GPs, and detailed information in A guide for Registered Medical Practitioners. However, I have been leading a session on OH for GP registrars for the past 10 years, and it is very rare to find a GP registrar who has ever seen or referred to DWP desk aids or other guidance.

So GPs and others have access to advice, but does ‘official’ guidance influence the way they behave when they are considering writing a Med 3 for the patient sitting in front of them? If GPs are currently unaware of (or disregard) the existing guidance, will new guidance on ‘fit notes’ have any impact?

Anecdotally, we know that Med 3s are sometimes issued like repeat prescriptions (on demand via the practice receptionist), and we know that GPs actually dislike being asked to provide certificates of any kind. There is an understandable irritation among GPs about the ‘get a note from your doctor’ approach to life’s little problems.

In a paper in the British Medical Journal in 2004,3 Susan Hussey and colleagues demonstrated a wide range of views among GPs on the misuse of sicknotes. My favourite is:

GP3 “Have you ever written anything really crap on a Med 3?”

GP4 “Yeah, I write ‘neurasthenia’ and I scribble it so even I can’t read it, and they have never asked for clarification, so they are obviously quite happy for you just to scrawl something totally illegible.”

In subsequent letters, views were polarised. One GP wrote: “No-one is in a better position to issue a sickness certificate than a general practitioner. He or she has the information at hand”. Another said: “We write sicknotes unthinkingly and inconsistently, doing so with good grace for those we like, and more grudgingly for those who make us feel angry or uncomfortable… imagine the chaos you can create for the honest employer”.

The University of Manchester’s Occupational and Environmental Health Research Group runs The Health and Occupation Reporting network (THOR). From research on work-related ill health and sickness absence,4 preliminary data suggests that GPs underestimate the length of sickness absence following work-related ill health in more than half the patients to whom they issue sicknotes.

Real change?

Will a new ‘fit note’ – electronic or otherwise – and guidance from the government really deal with these problems?

GPs will not spend time writing down what their patient might be able to do, assuming the employer is amenable to modifying the work. I wouldn’t be surprised if notes say: ‘Suggest referral to OH.’ And there aren’t enough trained occupational physicians and specialist nurses to take on the role that GPs might want to resist. The results from pilot studies will be most interesting.

In the meantime, here’s a personal view, which might not appeal to the government, employers or many of my colleagues. Let’s scrap medical certification for, say, the first four weeks of absence, and rely on self-certification. After all, that’s really what happens now.

And what would happen? I suspect that very short-term absence might rise a little, and those who currently take seven days off self-certified would take eight or nine days. But many of those who currently have four or six weeks, covered by Med 3s, may actually return to work sooner, as they don’t feel obliged to wait until the end of their sicknote, or to go back to their GP for a final note. They could just go straight back to work. And, of course, managers would be responsible for managing absence, rather than just passively accepting a Med 3.

It can’t be more challenging than an electronic ‘fit note’ that will make GPs uncomfortable.

Dr Gordon Parker is also a consultant occupational physician at Lancashire Teaching Hospital NHS Foundation Trust.


  1. Hussey S, Hoddinot P, Wilson P, Dowell J, Barbour R. Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland. BMJ 2004328:88-91

More resources on well notes online

Occupational Health and sister publication, Personnel Today have launched the Workplace Health Connections blog to encourage debate and information sharing among all those with a stake in workplace health.

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