Closed call for evidence

Fit Note Reform: call for evidence

Updated 25 April 2024

This was published under the 2022 to 2024 Sunak Conservative government

Presented to Parliament by the Secretary of State for Work and Pensions and the Secretary of State for Health and Social Care by Command of His Majesty. 

April 2024

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Ministerial foreword

A healthy economy is only possible with a healthy workforce. As well as providing an income, work enhances mental and physical health, enriches community life, and provides purpose. 

This government is dedicated to fostering long-term prosperity and economic growth, and we want to establish a strong and resilient labour market that opens up opportunities for all. Building on the ambitious £7 billion employment package announced at the spring budget in 2023, the government announced its new Back to Work Plan at the autumn statement, which will expand the employment support and treatment available and reform the ways that disabled people and people with disabilities interact with the state. However, there is still work to be done.  

While the UK’s economic inactivity rate is lower than the G7, EU and OECD averages, following the COVID pandemic, economic inactivity due to long term sickness rose by nearly half a million.[footnote 1] [footnote 2] Long term sickness is now the main cause of economic inactivity amongst the working age population[footnote 3]. But timely access to the right type of joined-up work and health support can prevent people with health conditions from falling out of work and give them the best chance of remaining, and thriving in work. 

Across England in primary care 93.8% of fit notes were issued as ‘not fit for work’[footnote 4]. This means that over 10 million fit notes each year are issued where the patient is simply signed off, resulting in a missed opportunity to help people get the appropriate support they may need to remain in work.

All too often, people are written off work without an objective assessment of what they could do with the right support, rather than what they cannot.

That is why we set out our plans to reform the fit note process in last year’s autumn statement. We want to facilitate timely patient access to specialised work and health conversations and support. We are testing shifting the responsibility for issuing the fit note away from primary care and reforming the way fit notes are issued so that people who can stay in work, or return to work sooner with the right help, are given exactly that. This will not only help create a system better tailored to an individual’s health and work needs but should also free up valuable time for GPs and primary care teams.  

Collaboration is key to achieving our ambitions. The fit note is part of a much bigger work and health picture. Healthcare professionals, employers, local authorities, the public and government all have a part to play. This call for evidence is an opportunity to seek your views and experiences of the current fit note process; how it supports work and health conversations, but also the challenges and the enhancements that would better support people to start, stay, and succeed in work. Please provide your views and ideas to inform these trials and our plans for wider fit note reform. 

A preventative healthcare system that integrates work and health services locally will support our vision to improve patient health outcomes, reduce health disparities, and help people get access to the support they need to return to and remain in work. 

Together, we can help build a healthier and more prosperous society for everyone.  

Mims Davies MP, Minister for Disabled People, Health and Work

Helen Whately MP, Minister for Care

Executive summary

This call for evidence will inform a programme of work announced at the autumn statement in 2023, to explore reforming the fit note process to support those with long term health conditions to access timely work and health support. We are gathering evidence to assess the impact of the current fit note process in supporting work and health conversations and exploring the enhancements stakeholders would require for the fit note to better support people to start, stay and succeed in work. We welcome all views, particularly from: 

  • employers 
  • healthcare professionals 
  • patients, carers and those who access fit notes
  • representatives of local systems or local system partners (for example, local authority, integrated care board and voluntary community social enterprise) 
  • interested academics and stakeholder organisations  

You can respond on behalf of an organisation or as an individual. The easiest way to participate in this call for evidence is by completing this online form.  

This call for evidence is part of a wider suite of activity to reform the fit note and will act as a prelude to a full consultation on specific policy proposals which will be launched later this year.

Fit note reform

Context

Good work is good for health.[footnote 5][footnote 6] As well as income, work gives an individual social interaction, a core role, identity, and purpose, among many other benefits. We know that work positively impacts people’s physical and mental health and wellbeing, and we want to support people to stay in, and return to, work and to fulfil their potential. 

Everyone will occasionally need some time off work when they are unwell. However, short-term absences can lead to longer absences.   

With the right support many people living with long term health conditions can succeed in work. Helping people with health conditions to start, stay and succeed in work is a crucial part of the economic success and wellbeing of every community. It also plays a key role in reducing health disparities. It creates the conditions for a more inclusive nation, but also for a healthier and more productive one. In 2022 to 2023, 14.8 million people reported a long-term health condition, which represents around a third of the UK’s working age population.[footnote 7] With access to the appropriate support and where clinically appropriate, staying in work or returning to work as quickly as possible is in many cases the best outcome for an individual. 

It is also very important that this support can be accessed in a timely way. The evidence shows that the longer an absence from work the lower the likelihood that someone returns to work and their health often worsens.[footnote 8][footnote 9]

The role of the fit note and the current limitations 

Fit notes are the medical statement used by eligible healthcare professionals to provide advice about the impact of a patient’s health on their ability to work. They are issued to employed people in order to evidence a request for sick pay from their employer and also for the purposes of supporting a claim for health-related benefits. 

The fit note was introduced in 2010 to replace the ‘sick note’ and to ensure patients received advice about the benefits of returning to work, and employers had the information they need to make changes to facilitate an earlier return to work.[footnote 10]  

The fit note should play an important role in the system helping to keep people in work with or without adjustment, as it is often the first opportunity a person experiencing a health issue will have to discuss the impact their condition is having on their ability to work. The 2010 reforms included a new option to allow a GP to indicate that a patient ‘may be fit for work subject to the following advice’ and provide general details of the functional effect of the individual’s condition and recommend common types of workplace adjustment: phased return to work, altered hours, amended duties and workplace adjustments. 

However, between October 2022 and September 2023 across England in primary care only 6.2% of fit notes were issued as ‘may be fit for work taking account of the following advice’, and this has remained relatively stable since we first collected data in 2016[footnote 11]. This means that over 10 million fit notes each year, of which a large proportion are repeat fit notes, are issued without any such advice, resulting in a missed opportunity to help people get the appropriate support they may need to remain in work.[footnote 12] 

To support and empower better conversations about work and health between employers and their employees, in 2022 we enabled nurses, occupational therapists, pharmacists, and physiotherapists to legally certify fit notes.[footnote 13] Yet there has been low take-up of this reform. Between April and September 2023, only 8.4% of fit notes were issued by these groups with the vast majority still issued by GPs.[footnote 14] To help address this, we updated our fit note guidance for healthcare professionals, employers and employees in October 2023.[footnote 15]

The fit note can be the first step to someone falling out of work and drifting into long term inactivity. Feedback suggests that a key issue with the current fit note process is that it does not reflect the diversity of needs when considering whether someone’s health condition impacts their ability to work. This is because: 

1. There is currently not enough capacity or specific work and health expertise in primary care to make an effective assessment of a patient’s ability to undertake work.[footnote 16] Fit notes can also be issued within secondary and community care, and while there is an ongoing project to embed the fit note in secondary care IT systems in England, GPs continue to issue most of them. This may be using valuable capacity that could be better utilised with patients. We know GPs spend over 30% of their time on indirect patient care (including issuing fit notes).[footnote 17] There is a missed opportunity for a patient and a relevant healthcare professional to discuss how they can stay in, or return to, work, or what adjustments could be made by their employer to offer them better support.[footnote 18]  

2. There is no established route to refer people to more tailored or intensive support if it is needed. People with different health conditions and in different types of employment often need tailored support to help them stay in and get back to work. Where further support is required, its availability can vary and is difficult to navigate.

This means that the current process is not meeting the needs of individuals, employers, and healthcare professionals in supporting people to start, stay and succeed in work: 

For individuals

Employees want to be fit and able to return to work as soon as they can, but often underestimate their ability to do so. We know that employees will benefit from being fit and able to return to work as soon as they can.[footnote 19] A prolonged absence from work often means people are less likely to return to work and as a result their health can worsen.[footnote 20][footnote 21][footnote 22] Getting access to the right type of support can help prevent health conditions from leading to unnecessary long-term absences from work. As an important point of contact, the fit note is a valuable opportunity to enable people to get focused advice and support about managing their health condition and work. But the current fit note process does not facilitate this.  

For employers

Employers want their employees to be fit and in work. Employers can support this through making adjustments in their workplaces, including supporting their employees to return to work more quickly where it is appropriate. Advice provided through the fit note can help employers to have quality conversations with their employees to enable them to return to work and remain in work. However, with just 6.2% of fit notes being “may be fit for work”, employers do not always get the information they need to give them confidence or understanding to have those productive and supportive conversations and in making appropriate adjustments for their employee. [footnote 23][footnote 24]  

For healthcare professionals

Healthcare professionals largely accept that good work is generally good for health and wellbeing[footnote 25]. Some healthcare professionals, particularly those with a special interest and training can, and do, get involved in conversations about work. Most, however, do not.[footnote 26] We know there are significant challenges in fitting in a high-quality work and health conversation into a typical consultation in General Practice, and it has always been recognised that most healthcare professionals issuing fit notes are not experts in occupational health.[footnote 27] Many healthcare professionals do not have access to the necessary time, resource, training or support to confidently offer good work and health advice that meets the complex and varying needs a patient might have. There is therefore a risk that too many people are signed off as unfit for work without a conversation about adjustments that could be put in place to enable them to carry on working.

Government wants individuals and employers alike to fully reap the benefits that fit note reform will bring.  

The government is aware that registered healthcare professionals working for private providers can and do supply online ‘work sickness certificates’ to patients for the purposes of claiming sick pay as an alternative to getting a fit note from their GP surgery. We are concerned about the risk of this system being abused and are therefore keen to understand if this practice is widespread and the views of employers, to inform policy thinking about the role of these services within the reformed fit note process. 

Our approach 

While fit note policy and regulations apply to Great Britain, fit notes are delivered in the health system, which is devolved. Government wants to develop and test a reformed fit note process in England that provides a more integrated work and employment support offer to help employers and employees to reduce sickness-related absence and in turn free up valuable time for healthcare professionals. 

At Autumn Statement 2023, the Chancellor announced £24 million to begin designing and implementing “trailblazers” in a number of integrated care systems (ICSs) in England, to test offering better triage, signposting and support to those who have received a fit note for a prolonged period of time. These trailblazers will build on the WorkWell vanguards due to be announced this spring.

The WorkWell services will provide a single, joined-up assessment and gateway into local employment support services, to help people manage their health condition and get back to work sooner. This is part of an ambitious programme to support disabled people and people with health conditions to start, stay and succeed in work. These include a new voluntary supported employment programme called Universal Support which will provide wraparound support to 100,000 people a year in England and Wales once fully rolled out, and the introduction of Employment Advisers in Musculoskeletal services, building on the successful Employment Advisers in NHS Talking Therapies being rolled out nationally in England.

The ambition is to co-develop a new process that brings healthcare and employment systems together to support people who are at risk of falling out of work, or who have already fallen out of work, due to ill health. The core components of this new process that we are testing are: 

  • a triage service that supports people seeking a fit note into a pathway that best suits their individual health and employment needs

  • an assessment of someone’s ability to do their job, and a work and health conversation with a healthcare professional or with a work and health adviser. Healthcare professionals and work and health advisers will have work and health training and dedicated time, making them better placed to take into consideration a wider set of factors that affect someone’s ability to work  
  • the ability to refer people to more intensive work and health support and assist employers in accessing expert work and health support through Occupational Health services, where appropriate

Government believes these core components will produce a fit note service that facilitates faster and simpler, work and health support. We understand the importance of developing a support offer that aligns with local needs and circumstances. Integrated care boards (ICBs), working closely with their integrated care partnership stakeholders, including local employers, primary care, adult social care, council services and voluntary and community sector organisations, will have flexibility to design their approach to best suit their local population and local services, and to evolve their model as they test and learn more about what works. 

The trailblazers will recruit clinical and non-clinical professionals into roles who should be provided with additional training and support to conduct robust and in-depth work and health conversations with patients. Individuals will be provided with advice and guidance on how they might be able to start, stay in, or return to, work with the support of their employer. This new delivery model being tested will explore how the wider health system can take responsibility for issuing the fit note, and situate it within a new service in WorkWell vanguard sites. This service will allow primary care teams to use their valuable time more efficiently and provide people with tailored health and employment support so that they can better manage their health condition in work. 

The impact of this new approach in trailblazer sites will be evaluated and used to inform future policy design. 

The reformed fit note process aims to integrate smoothly with WorkWell, enabling the people who need it to have a work and health conversation, with a single, joined-up assessment and gateway into local employment support services. It will also complement the role of Occupational Health in ensuring employers understand and benefit from more expert work and health support to retain and support those in work.  

Whilst staying in work or returning to work as quickly as possible is in many cases the best outcome, we understand that the right support looks different for different people. For example, some people may need a fit note for short or time-limited illness (such as an infection or to recover from an injury or surgery) and can return to work promptly without additional support. Others may require a more detailed assessment and discussion about their work and health, including signposting to more intensive support where appropriate. Our commitment to reform the fit note process, and this call for evidence, will help us to better understand who needs additional support, and how government can enable them to access it. 

In reforming the fit note process in England, we are committed to working collaboratively with healthcare professionals, NHS bodies and other stakeholders to develop and design a system-wide approach to this process. In addition to this co-design work, we want to understand and consider a wide range of views and lived experiences, including individuals as service users, carers and patients.

Scope 

Government wants our fit note reforms to be underpinned by as much evidence as possible and informed by a wide array of perspectives. The evidence gathered, alongside the trailblazers, will inform a more detailed consultation later in 2024 on specific policy proposals. While fit note policy and regulations apply to Great Britain, health is a devolved matter.  We are keen to hear a broad range of views from across the UK to inform future policy development. 

We know that the quality of health advice in primary care has been affected by capacity and knowledge constraints on job roles and occupational health[footnote 28][footnote 29], and that strengthened communication lines between healthcare professionals, employers and patients would strengthen this advice and facilitate better work and health conversations[footnote 30]. We want to go further and broaden the evidence, views and insights we hold, in order to better help people to start, stay and succeed in work. 

This call for evidence is focussed on the impact of the current fit note process in supporting work and health conversations and the enhancements stakeholders would need to better support people to start, stay and succeed in work.  We are particularly interested in views and evidence relating to the following themes:

Individuals’ and carers’ experience

The patient’s experience within the current fit note process and what opportunities there are to enhance or reduce frictions in the user experience.  

Clinicians’ and non-clinical professionals’ experience

The experience of clinical and non-clinical professionals throughout the current healthcare system, and views on how to improve the fit note process and work and health conversation. This includes the support required to improve information provided on the fit note for patients and employers. 

Employers’ experience

Employer experiences of using fit notes and the support required to use the fit note to better support their employees to return to work, including in relation to the role of Occupational Health.  

Private work sickness certificates

The government is aware of private providers who offer to supply online fit notes from a registered healthcare professional for a fee. They are often described as a ‘work sickness certificate’ and can provide an individual with evidence for sick leave and/or sick pay without going to a GP practice. The government is interested in whether the provision of online private work sickness certificates is something that should be reviewed and is seeking views on employer and employee experiences. 

Information gathering and wider system integration

The potential to gather more information from those who need a fit note to better support work and health conversations and outcomes. In particular we are interested in views on how digital channels can support gathering this information and any risks and opportunities.

The Department for Work and Pensions (DWP) and the Department of Health and Social Care (DHSC), together as the Joint Work and Health Directorate (JWHD), are seeking views on what our current and future policy considerations should include when reforming the fit note process. The set of questions should not be taken to present that DWP and DHSC have reached a settled policy position.

How to respond

Please submit your responses via this online form.

If you have any issues, please contact [email protected].  

If you prefer to respond via email or post, please send your response to [email protected] or: 

The Fit Note Team 
Department for Work and Pensions 
Caxton House 
Tothill Street 
London 
SW1H 9NA 

When responding by post or email please indicate whether you are responding as a patient, carer or individual who accesses fit notes, an employer (and whether the organisation is a large employer or SME), a clinical or non-clinical healthcare professional, a representative of local systems or local system partner, an interested academic, representing the views of a stakeholder organisation, or in another capacity.  

Please also indicate where you are located geographically (north-east, north-west, Yorkshire and The Humber, East Midlands, West Midlands, East of England, London, south-east, south-west, Wales, Scotland, Northern Ireland, or UK wide).

Questions 

The following section sets out the questions seeking further evidence. There are a number of questions, and you do not need to answer all the questions in this call for evidence. Please focus on the questions that you feel able to give us views and evidence on. We would welcome views and evidence from across the UK.  

There is no minimum word limit. We strongly encourage a maximum limit of 500 words per question (not including references). We recommend providing responses which contextualise and summarise the key points of the evidence they reference, as these are likely to be most effective. Given the volume of responses expected, submissions exceeding this recommended length may not be read in their entirety.

About you 

1. Please tell us in what capacity you are responding: 

  • a patient, carer or person who accesses (or has accessed) fit notes 
  • a large employer 
  • a small and medium-sized enterprise  
  • a clinician or non-clinical healthcare professional 
  • a representative of a local system or local system partners ( for example, local authority, integrated care board or voluntary community social enterprise) 
  • an academic 
  • a stakeholder organisation 
  • other  

2. If you are responding on behalf of an organisation, what is its name? 

3. If you are responding as a clinician or non-clinical healthcare professional, please tell us what setting you work in? 

  • primary care 
  • secondary care 
  • community or social care 
  • other

Overarching views of the fit note process 

4. How effective do you feel current fit note process is at supporting individuals’ or patients’ work and health needs?   

  • very effective 
  • effective 
  • neither effective nor ineffective 
  • ineffective 
  • very ineffective 
  • unsure  

5. What works well with the current fit note process to support individuals’ or patients’ work and health needs?  

6. What can be done to improve the fit note process to meet individuals’ or patients’ work and health needs?

Individuals’ and carers’ experience

7. How useful do you feel the information in ‘may be fit for work’ fit notes is at supporting individuals’ or patients’ work and health needs, and why?   

8. What, if any, additional information would be useful in ‘may be fit for work’ fit notes to support individuals or patients in returning to work from sickness absence? 

9. Have you ever purchased a ‘work sickness certificate’ from an online private company advertising themselves as a fit note or sick note service. 

  • yes 
  • no 
  • unsure 

10. What motivated you to use this online service to purchase a ‘work sickness certificate’? 

11. What was the experience of purchasing a ‘work sickness certificate’ from an online company like?

12. If the ‘work sickness certificate’ provided advice to support return to work, how useful was this advice? 

  • very useful 
  • fairly useful 
  • neither useful or not useful 
  • not very useful 
  • not at all useful 
  • unsure 

13. Please tell us why you feel that way about the advice provided in the ‘work sickness certificate’? 

14. Was the ‘work sickness certificate’ accepted by your employer?

  • yes
  • no
  • unsure

Employers’ experience 

15. How effective do you feel the current fit note process is at meeting employer needs? 

  • very effective 
  • effective 
  • neither effective nor ineffective 
  • ineffective 
  • very ineffective 
  • unsure  

16. What works well with the current fit note process for employers?  

17. What do employers feel could be improved with the fit note process so that it meets their needs? 

18. What, if any, additional information might be helpful for employers to have within may be fit for work fit notes to support employees to successfully return to work from sickness absence? 

19. What do employers need to feel confident in having in-depth work and health conversations with employees?

20. Have you ever received a ‘work sickness certificate’ or other form of fit or sick note from an employee issued by an online company advertising themselves as a fit or sick note service? 

  • yes 
  • no 
  • unsure 

21. What was the experience of receiving a ‘work sickness certificate’ or other form of fit or sick note from an employee issued by an online private company like? 

22. If the ‘work sickness certificate’ provided advice to support employee’s return to work, how useful was this advice? 

  • very useful 
  • fairly useful 
  • neither useful or not useful 
  • not very useful 
  • not at all useful 
  • unsure 

23. Please tell us why you feel that way about the advice provided in the ‘work sickness certificate’?

Clinicians’ and non-clinical professionals’ experience

24. Do you agree that issuing fit notes is a good use of a General Practitioner’s (GP) time? 

  • strongly agree 
  • agree 
  • neither agree nor disagree 
  • disagree 
  • strongly disagree 
  • unsure 

25. Please tell us why you feel that way about fit notes being a good use of GP’s time? 

26. What can be done to improve the fit note process to meet healthcare professionals’ needs to provide more health and work support for patients? 

27. What are the enabling factors for healthcare professionals to have an in-depth work and health conversation with individuals requesting a fit note? 

28. What are the challenges for healthcare professionals to have an in-depth work and health conversation with individuals requesting a fit note? 

29. What are the enabling factors for healthcare professionals in providing detailed and applicable advice in ‘may be fit for work’ fit notes to support patients’ work and health needs?  

30. What are the challenges for healthcare professionals in providing detailed and applicable advice in ‘may be fit for work’ fit notes to support patients’ work and health needs? 

31. What steps might the government take to support healthcare professionals or work advisers to have an in-depth work and health conversation with individuals requesting a fit note? 

32. Which patients do you feel would benefit most from more in-depth work and health conversations?   

33. How can those patients who would benefit most from more in-depth work and health conversations be identified? 

34. What, if any, are the benefits and drawbacks of patients using online private companies to issue online ‘work sickness certificates’?

Information gathering and wider system integration

35. What knowledge, skills and support would healthcare professionals need to accurately assess the impact of a patient’s health condition on their ability to work?  

36. What knowledge, skills and support would work advisers need to accurately assess the impact of a patient’s health condition on their ability to work?  

37. How could we utilise digital and telephony systems to gather information to better support work and health conversations? 

38. How could the fit note process more effectively link to different forms of work and health support, such as vocational rehabilitation, occupational health, and employment support?

Miscellaneous

39. What, if anything, can be done to incentivise and increase “may be fit for work” fit notes issued by healthcare professionals, where being in work is the best outcome?

40. Please can you provide us with any case study examples of where the fit note process is working well to support people with health conditions to return and remain in work? 

41. Is there anything else you would like to tell us about the fit note process? 

Duration 

This call for evidence will be open until 8 July 2024.

Next steps 

The views and ideas gathered through this exercise will inform the priorities and strategy for fit note reform. We will launch a consultation later this year to gather your views on specific policy proposals.

Personal information charter  

DWP and DHSC personal information charters can be accessed here:  

Personal information charter - Department for Work and Pensions - GOV.UK (www.gov.uk) 

Personal information charter - Department of Health and Social Care - GOV.UK (www.gov.uk)

Freedom of Information 

The information you send us may be passed to colleagues within the DWP and DHSC. All information contained in your response, may be subject to publication or disclosure if requested under the Freedom of Information (FOI) Act 2000. By providing information for the purposes of this call for evidence exercise, you understand that it could be released as part of a FOI request.  

If you want the information in your response to the call for evidence to be kept confidential, you should explain why as part of your response, although we cannot guarantee to do this, and this does not mean that it will be automatically blocked from release as part of an FOI response. 

DWP and DHSC always protects personal information under their personal information charters and these details would be withheld from release as part of an FOI response.  

The Information Commissioners Office (ICO) are the independent regulator on FOI requests and further details on FOIs can be accessed here:

How to access information from a public authority ICO 

If you would like to make an FOI request to DWP or DHSC please follow the steps set out on the DWP or DHSC websites: 

Make a Freedom of Information (FOI) request to DWP 

Make a Freedom of Information (FOI) request to DHSC

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