The fit note is five years old – is it ready to leave the nursery?

Many GPs feel that they do not have sufficient time or skill to complete fit notes – particularly the “may be fit” option

Independent research published by the University of Nottingham in 2015 shows that the fit note is misunderstood by employers and GPs and advises that more training and investment is needed to realise its potential. Dr Carol Coole and Avril Drummond, who worked on the research, explain more.

The UK Statement of Fitness for Work, or “fit note” was introduced in 2010 to facilitate returns to work and reduce avoidable sickness absence by encouraging GPs to focus on what a patient can do at work, rather than what they cannot do. GPs now have the option of advising that a patient is “not fit for work”, or that they “may be fit” for work if appropriate modifications are made.

Since its introduction in 2010, several individuals, groups and organisations have published results of research and investigations about the success of the fit note. These studies have included research reports commissioned by the Department for Work and Pensions (DWP) and sickness absence surveys conducted by employer organisations such as the Engineering Employers Federation (EEF).

Independent research has also been carried out, including a study recently completed by our research team at the University of Nottingham, entitled “Getting the Best of the Fit Note” (Coole et al, 2015). This study was funded by the Institution of Occupational Safety and Health, and ran between April 2013 and September 2014.

How was this study different?

Rather than reporting on the viewpoint of one stakeholder group, for example GPs or employers as in previous studies, we wanted to involve a range of stakeholders, namely GPs, employed patients and employers, to find out how the fit note could best be used by reaching a consensus of their views.

Consensus was reached for a total of 67 recommendations concerning fit note use. These recommendations cover the format, completion and management of the fit note; communication pathways between the stakeholders; and education and training in fit note use. Some examples of these recommendations are shown in the box below.

Examples of recommendations to improve fit note use where consensus was reached

  • GPs should state how the patient’s condition affects their ability to work (ie the functional effects of the condition) on both “not fit” and “may be fit” notes.
  • When completing a fit note, the option of “may be fit” should always be considered.
  • There should be local audits of fit notes to ensure that fit notes are completed according to the most up-to-date DWP guidelines.
  • Employers must ensure strict confidentiality in their management of fit note information.
  • Employers must inform their workforce about how their organisation manages the fit note.
  • Other healthcare professionals with relevant training and competency should be able to complete fit notes.
  • Training in the use of the fit note should include GPs, employers and patient/employee representatives so that each can hear the others’ viewpoint.

We also collected over 900 copies of “real” fit notes, and asked those who either issued them (GPs), received them (employed patients) or used them (employers, including HR professionals, managers and OH advisers) to comment on their usefulness.

Forty-three participants were also interviewed. We looked closely at the fit notes collected in terms of completeness, quality of information and method of completion. As these fit notes were issued more recently than many previous published studies, they are reflective of increased experience in fit note use.

So what did our study tell us about the fit note?

Overall, the main stakeholder groups think that the idea behind the fit note is good. Employers, GPs and patients all report that they favour the idea of helping people to stay at work, or to assist them in returning to work when they can, despite not being fully fit, and so avoiding unnecessary sickness absence.

However, our research shows that actual fit note use is not reflecting these attitudes. Only a minority of fit notes actually advise that a patient “may be fit” for work.

Few provide much in the way of useful information on a patient’s condition, when they are likely to recover, or why they are unable to work; often the doctor has omitted to state whether or not they need to assess the individual again before they return to work, making it difficult for employers and employees to plan ahead.

Many GPs feel that they do not have sufficient time or skill to complete fit notes – particularly the “may be fit” option, and would rather not have this responsibility.

Some employers would rather not receive “may be fit” notes, because they perceive that it creates an extra burden in making adjustments.

Although our recommendations have the potential to improve fit note use, there would be considerable financial, legal, practical and professional challenges to implementing these changes.

What’s in a name?

Perhaps one of the more confusing aspects of the fit note is that, in reality, there is no such thing as a note which advises that a patient is “fit” for work. According to the DWP, the fit note refers to both “may be fit” and “not fit” notes. However, in our study, we found that participants often referred to “may be fit” notes as “fit notes” and “not fit” notes as “sick notes”.

Some employers and employees still believe that patients have to be signed “fit to work” again by their GP before they can return to work.

When the DWP piloted the new Statement of Fitness for Work, the option of the GP advising that a patient was “fit for work” was included, however it was later dropped. The reasoning was that this would be covered by the GP indicating on the fit note whether or not they needed to assess the patient again at the end of the advised fit note duration – however, we found that this section is often not completed in practice.

Terminology is also important when examining the evidence. Research studies, or participants in the studies may refer to “fit notes”, but it is not always made clear if the fit notes under investigation are “may be fit” notes, “not fit” notes, or both. This distinction – or lack thereof – affects any conclusions that might be drawn from the research.

Understanding the fit note

As we have suggested, there are misconceptions and misunderstandings about the fit note and how it is intended to be used. As well as issues around fitness for work, some employers remain unaware, or unwilling to accept, that the fit note is advisory and that an employee can return to work before the expiry of the fit note – even if signed as “not fit” during this period – if they and the employer are in agreement.

Some employers feel that this has shifted the responsibility as to whether a patient is work “fit” from GPs to them, and they worry about the potential insurance implications.

Likewise, some employers – and some GPs – think that the GP is obliged to make specific recommendations on workplace modifications on a “may be fit” note. In fact, the guidance from the DWP states that the GP should only include this information if they feel able to provide it (DWP, 2013). The information that they are expected to provide – in the free-text comment box – is on the functional effect of the patient’s condition.

Our study showed that this was one of the sections that employers wanted most – ie “what is it about the patient’s condition that makes it difficult for them to work?” and yet GPs rarely commented on this in the fit note.

Why are there misconceptions and misunderstandings about the fit note?

When the concept of the fit note was first introduced by Dame Carol Black, it was reported that there would be training provided to healthcare professionals in its use (DWP and DoH, 2008). A National Education Programme in Work & Health was established for GPs, however, the half-day workshop was optional, and there was a charge to attend.

Although the programme was perceived by the participants to be useful, it is not known if or how it affected fit note completion. The programme is not currently available, and unconfirmed reports indicate that only 12% of UK GPs attended. An online element – Healthy Working UK – can still be accessed by GPs, but, once again, details of uptake are not available.

As to the education and training for employers in fit note use, this seemed to be very variable. In our study, some participants had received some training when the fit note was first introduced, but most had not received any. It seems even less likely that patients or employees received any instruction in what fit notes are or how to use them, despite the patient/employee being the key stakeholders.

Although the fit note is the property of the employee, we found that most fit notes are given to the employer, rather than a copy being taken by the employee as intended. Since the fit note was introduced, online detailed written guidance has been provided by the DWP for each of the five main stakeholder groups (Coole et al, 2015). However the guidance for employers, GPs and patients has been updated more than once.

There have been subtle but important changes in the guidance that users may not be aware of, including the expectation that GPs should now advise whether or not an individual is fit for “any” work (not just their previous or current work) and the assurance that GPs are not required to advise on particular work modifications. In our study, few of the participants were aware of, or were referring to, this guidance.

Could other healthcare professionals fulfil this role?

As GPs are clearly struggling to use the fit note as intended, is there a role here for other healthcare professionals? Two other initiatives deserve a mention.

First, there is the Allied Health Professions (AHP) Advisory Fitness for Work Report, introduced in 2013. The format is very similar to the fit note, but the report is larger, with more space available for therapists to comment on the “difficulties” that a patient is reporting, and on “recommendations and goals” to address these difficulties. The report can be used by the patient instead of a fit note as evidence of fitness to work and to claim statutory sick pay from employers, or it can provide more detailed and relevant information to GPs to assist them in completing fit notes. Although it cannot be used to claim state benefits, this report would appear to have considerable utility.

Second, there is the new Fit for Work service, where the fit note can be replaced by a return-to-work plan, completed by an OH adviser, therapist or nurse who has undertaken specific training in assessing and advising on work and health. However, this is a voluntary scheme, and is dependent on the employee’s willingness to share the plan with their employer, and the employer’s willingness to accept it.

Future impact

At the moment it appears that the fit note is still in early development and is unlikely to make it to the next level without more investment in time, resources, training, commitment and legislation.

Future research needs to investigate the impact of the AHP report and the Fit for Work service on fit note use, sickness absence and work retention, and the extent to which the recommendations made in our own study are taken up.

References

Coole C, Drummond A, Watson PJ, Nouri F, Potgieter I (2015). Getting the Best from the Fit Note. Wigston: Institution of Occupational Safety and Health.

Department for Work and Pensions (2013) Guidance for GPs, employers, hospital doctors and occupational health practitioners on using fit notes (statements of fitness for work).

”Improving heath and work: changing lives. The Government’s Response to Dame Carol Black’s Review of the health of Britain’s working-age population” (2008). Presented to Parliament by the Secretaries of State of the Department for Work and Pensions and the Department of Health.

Allied Health Professions Advisory Fitness for Work Report (2014).

Fit for Work service

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