Exploring perceptions and attitudes towards the extension of fit note certification

Question 1

Executive Summary

Accepted Answer

This summary presents the key findings from qualitative research with a broad range of healthcare professionals (HCPs), employers and patients conducted by Ipsos MORI on behalf of DWP/DHSC (Employers, Health and Inclusive Employment directorate). The research explores different HCPs’, employers’ and patients’ experiences and views of the current fit note process, as well as their perceptions and attitudes towards extension of fit note certification powers to a wider range of HCPs.

This research report indicates that the extension of fit note certification powers to a wider range of appropriate HCPs is likely to be well received by HCPs, employers and patients. The findings indicate a range of potential benefits to extending fit note certification, including:

Enabling more detailed and tailored workplace advice to be provided to both patients and their employers.
Reducing current time and workload pressures on GPs.
Minimising duplications in effort and resources in the current fit note process.
Ensuring more effective use of professional healthcare time and NHS resources.
Providing a better ‘fit note experience’ for patients, employers and HCPs.

The research also highlights broad consensus between patients, employers and HCPs regarding the qualifications, skills and experience needed to issue fit notes. These include the necessity for HCPs to operate at an advanced level, to be registered and licensed to practise clinically, and to have received relevant training on how to assess fitness for work and complete and issue fit notes.

Despite this positive reception, a number of challenges to the extension of fit note certification powers have been raised. These include concerns that:

Some HCPs may not be as professionally qualified and regulated as GPs and hospital doctors to assess fitness for work and issue fit notes.
HCPs may be able to issue fit notes for health conditions outside of their scope of clinical practice.
Poor accessibility to patient clinical records may lead to duplicate fit notes being issued.
Extension of fit note certification powers may not resolve the current discrepancy between the level of detail that employers expect from a fit note and the type of workplace advice that HCPs are required to provide within fit notes; although widening certification to include HCPs, such as physiotherapists and occupational therapists, may potentially improve the return to work advice provided.

Based on these findings, this report concludes with a number of recommendations to further enhance the current fit note process and support the effective implementation of extension to fit note certification powers in the future.

Question 2

Acknowledgements

Accepted Answer

The authors at Ipsos MORI would like to thank the team at the Work and Health Unit, in particular Helen Stinson and Nicola Moss, for their thoughts, contributions, and enthusiasm throughout this project.

We would also like to thank our colleagues at Ipsos MORI who helped with recruitment, fieldwork and analysis.

Last, but by no means least, we would also like to thank all of the employers, patients, and HCPs for taking part in the research.

Question 3

The authors

Accepted Answer

This report was authored by researchers at Ipsos MORI:

Sarah Fullick (Associate Director)
Kelly Maguire (Senior Research Executive)
Katie Hughes (Graduate Research Executive)

Question 4

Glossary and abbreviations

Accepted Answer

Term	Explanation
Acute condition	Acute illnesses tend to be of a short duration. They may be minor or serious. Minor acute illnesses include some of the most common problems, such as upper respiratory tract infections or skin rashes. Major acute illnesses may present as an exacerbation of an underlying chronic illness, such as a myocardial infarction, or the sudden onset of a previously undiagnosed condition, such as epilepsy^{[footnote 1]}.
Advanced Nurse Practitioner (ANP)	ANPs are nurses educated to master’s level in clinical practice who have the freedom and authority to make autonomous decisions in the assessment, diagnosis and treatment of patients^{[footnote 2]}.
Allied Health Professional (AHP)	AHPs tend to be educated to degree level and are professionally autonomous practitioners^{[footnote 3]}. There are 14 allied health professions, including physiotherapists, occupational therapists and speech and language therapists^{[footnote 4]}.
Chronic condition	Chronic conditions are long-lasting, have no cure and are managed with drugs or other treatment, for example diabetes.^{[footnote 5]}
Healthcare Professionals (HCPs)	HCPs are qualified and professionally regulated practitioners who provide some form of specialist healthcare to patients. These roles include both medical and dental staff, such as doctors, nurses, paramedics and pharmacists.
Human Resources (HR)	HR is a department within an organisation with responsibility for managing and developing employees. Key roles may include recruitment, payroll and providing employment and legal advice.
Long-term sickness absence (LTSA)	An instance of sickness absence from work lasting four or more weeks.^{[footnote 6]}
Large employers	Employers with 250 or more permanent employees.
Medium employers	Employers with 50-249 permanent employees.
Occupational health (OH)	OH are advisory and support services that help to maintain and promote employee health and wellbeing through the provision of direct support and advice to employees and managers.
Occupational Sick Pay (OSP)	OSP is a form of sick pay provided by employers that is above the statutory minimum (i.e. Statutory Sick Pay).
Self-certification	This refers to the period of time lasting less than seven consecutive calendar days when an employee does not need to provide medical evidence to their employer for sickness absence.
Small employers	Employers with 2-49 permanent employees.
Statutory Sick Pay (SSP)	SSP is the minimum amount that employers must pay their staff who are too ill to work. At the time of writing, SSP was set at £92.05 per week for up to 28 weeks^{[footnote 7]}.

Question 5

1.  Summary

Accepted Answer

1.1 Background to Report

Employers, Health and Inclusive Employment directorate (EHIE) includes the cross-government Work and Health Unit, jointly sponsored by the Department for Work and Pensions and the Department of Health and Social Care. EHIE leads the Government’s strategy to support working age disabled people, and people with long term health conditions enter, and stay in, employment.^{[footnote 8]} In the 2017 Improving Lives: The Future of Work, Health and Disability Paper, the Government announced its commitment to extend fit note certification powers beyond General Practitioners (GPs) and hospital doctors to a wider range of healthcare professionals. This commitment arose from earlier consultation with key stakeholders which concluded that reform to fit note certification had the potential to reduce clinical and administrative burdens on GPs, improve the quality of health and work conversations and support the NHS’ multi-disciplinary approach to patient-focused clinical care. This research explores how different healthcare professionals (HCPs), employers and patients experience and view the current fit note process, their perceptions and attitudes towards the suitability and acceptability of extending fit note certification powers to a wider range of HCPs as well as offering insight into the ways in which future legislative reform can be most effectively and efficiently implemented in practice.

1.2 Methodology

Between April and June 2019, Ipsos MORI conducted 68 in-depth qualitative telephone interviews with a range of different individuals, including patients, employers and HCPs working within the NHS. The number of interviews completed by each participant group is presented below.

Groups	Completed interviews
GPs	10
ANPs	10
Other HCPs	10
Employers who have experienced fit notes	17
Employers who have not experienced fit notes	6
Patients	15
Total	68

To capture a range of different experiences and perceptions towards the current fit note process and proposed legislative reform, recruitment for this study was undertaken across Great Britain and from a range of different urban and rural localities. In addition, individuals were purposively recruited for their capacity to provide insight into the experiences and perceptions of:

Employers from different industry sectors with varying numbers of permanent employees working in both manual and office-based environments.
Employers working at different levels of an organisation, such as line managers, business owners and HR staff.
HCPs working across the NHS who both currently assess and issue fit notes as well as those professions potentially best placed to certify fit notes in the future (please see the appendix for a further breakdown of recruited HCPs).
Patients with experience of a physical or mental health condition who received a fit note while in employment^{[footnote 9]}.

1.3 Key findings

1.3.1 Chapter Three: The fit note in context

All of the participant groups acknowledged that good quality work can impact positively on an individual’s health and wellbeing, particularly their mental health. Work was described as providing individuals with structure, routine and purpose, as well as the opportunity to socialise with work colleagues and gain financial security. As a result, many of the participants explained that a workplace culture which provided good pay, a supportive environment, a good work-life balance and promoted a culture which valued all employees performed a critical role in promoting and sustaining good health and wellbeing in employment. HCPs appeared to particularly advocate that paid work promoted and maintained an individual’s physical and mental health and often explained that long-term sickness absences appeared to considerably reduce the likelihood that a patient would be able to successfully return to work in the future.

In addition, there was broad agreement across all of the participant groups that HCPs, employers, work colleagues, family and friends as well as the individual and wider society should support those in ill health. In particular, it was reported by the majority of participants that:

Individuals in poor health are responsible for actively seeking help from HCPs and alerting their employers when they become unwell.
Employers are responsible for ensuring that basic health and safety standards are met in the workplace and fostering a supportive workplace environment.
HCPs are responsible for providing appropriate assessment, diagnosis and treatment of individuals in poor health.

The study found that individuals in poor health are able to provide their employers with other forms of medical evidence than the fit note. This included the AHP Health and Work Report, the Patient Care Reference in Scotland, AHPs’ reports to GPs and attendance slips. They can be provided by HCPs such as pharmacists, occupational therapists, physiotherapists and ANPs. The other forms were reported to provide employers and GPs with more specific and detailed advice about the nature of an individual’s health condition and the implications for the job role, that the fit note was not designed to provide. However, these were ultimately designed to support and further enhance the existing fit note process as opposed to competing with or replacing it.

1.3.2 Chapter Four: Views on fit note extension

All of the participant groups expressed interest in, and were receptive to, proposals to extend fit note certification powers to a wider range of HCPs. Such a policy change was noted to have the potential to provide patients with greater continuity of care, to allow for the provision of more detailed fit notes and reduce current time and workload pressures on GPs. When concerns were expressed, however, these tended to centre on fears that a small number of employers and patients may not perceive fit notes written by HCPs to be valid, that the extension may potentially add to the workload burdens of additional HCPs and that current poor access to clinical records may possibly lead to the issue of multiple and duplicate fit notes.

There was nonetheless a strong sense across the participant groups that the potential benefits of the fit note extension would outweigh these risks. In many cases, these risks were often noted to be effectively mitigated through:

Ensuring that all HCPs certified to issue fit notes have the appropriate level of qualifications, skills, experience and training.
An effective communication campaign which raises awareness of the fit note reform and the capacity of a wider range of HCPs to provide valid and suitable workplace advice.
A training programme for all HCPs (including GPs) which provides an overview of the relationship between work and health, guidance on how to effectively assess fitness for work and potential workplace adjustments.
A small-scale pilot of the fit note extension with a robust evaluation to monitor its implementation and impact.
Enhanced IT infrastructure which provides wider access to patient clinical records and improves communication between different HCPs.

Overall, there was a broad consensus across the participant groups about the type of qualifications, skills and experience necessary to provide suitable fit notes. Importantly for this research, when prompted to think about the suitability of extending fit note certification powers to five particular healthcare professional roles, ANPs, specialist nurses in occupational health, physiotherapists, occupational therapists, pharmacists and mental health professionals, the majority were considered to be suitably qualified, knowledgeable, experienced to assess fitness for work and issue a fit note. As a result, only pharmacists were considered by most of the participant groups to not have adequate access to patient clinical records, appropriate clinical training or be working in a context which would facilitate effective assessments of fitness for work.

1.3.3 Chapter Five: Assessing fitness for work

Over the course of the study, six different circumstances were identified which would lead to a fit note being issued, including:

Self-certification: this is when an individual requests a fit note either because they or their employer is unaware of their capacity to self-certify, or an employer wants proof of an individual’s poor health.
Requesters: these are individuals who book an appointment to specifically request a fit note rather than primarily to discuss a health condition.
Long-term sickness absences: these are individuals who have been assessed as not fit for work for an extended period of time and, therefore, are often updating long-standing fit notes or require reassessment.
Unknown conditions: these are cases when an individual books an appointment to discuss a health complaint. In most of these cases, the necessity for a fit note arises from assessment of health and conversations about health and work.
Routine patients: these are cases when individuals have a planned operation in hospital. In these cases, the fit note is often secondary to the operation itself and usually issued at a later date either by the hospital doctor or GP.
Emergencies: these are cases when the individual presents symptoms that require emergency treatment, i.e. appendicitis.

The majority of GPs and ANPs reported that these forms of discussions framed their healthcare assessments, enabling them to build a holistic picture of their patient. However, GPs and ANPs described how they often did not have the time to provide accurate assessments of fitness for work and this led them to frequently offer only brief and non-specific workplace advice on fit notes. Time constraints appeared to be particularly challenging when a patient did not agree with their assessment of their fitness for work. In these cases, many of the GPs often explained how they had little choice but to provide a short-term fit note and ask the patient to return to clinic for a reassessment to have more in-depth work and health conversations. Importantly for this research study, some ANPs explain that in some of these challenging cases they currently refer the patient to their GP for a second opinion of their fitness for work. They explained how this action ensured that the fit note issued best met the needs of the patient but also helped to safeguard the relationship between the ANP and the patient, so they could continue to offer treatment and care.

1.3.4 Chapter Six: Views on the ‘may be fit for work’ option

On the whole, all of the participant groups viewed the capacity for an individual to be assessed as ‘may be fit for work’ with workplace adjustments as a positive way to support individuals to remain in or return to employment^{[footnote 10]}:

HCPs explained that it enabled patients to benefit from the positive effects of
employment as their health improved
HCPs also indicated that it allowed individuals to adjust gradually to their usual work routines and so frequently prevented the need for further sickness absences
Employers described how workplace adjustments provided their employees with a gentler introduction to full-time work whilst enabling the organisation to continue to retain their skills, experience and productivity
Patients often described how appropriate workplace adjustments supported their longer-term recovery, particularly helping many to maintain or improve their mental health and sense of wellbeing.

However, the majority of participants also expressed the need for further information and guidance about the types of suitable workplace adjustments that HCPs could recommend and how this advice could be adequately implemented at work by employers. A number of issues were highlighted by the different participant groups which help to explain why there are currently relatively few ‘may be fit for work’ fit notes which provide workplace advice:

GPs and ANPs often explained how they deliberately keep the level of detail on fit notes vague to help facilitate conversations between their patient and employer.
GPs and ANPs expressed concern that employers may not always implement workplace adjustments flexibly and appropriately, leading their patients to have to assume duties they are not comfortable with given their health condition.
Employers often require more detailed assessments of fitness for work in order to feel confident their actions will support their employers at work.
Employers are sometimes unwilling to accept the risk of allowing an employee to return to work unless they have been assessed as ‘fully fit’ for work, especially those operating in manual or hazardous environments.
Patients frequently described experiences of their employer being unable to understand and translate the workplace adjustments on their fit notes and, in some cases, having to regularly remind their employer of any implemented adjustments.

A key finding of this research study is the current discord between the level of detail that many employers expect from fit notes and the type of detail that HCPs are able to offer. This appears to suggest that the extension of certification powers may not necessarily resolve the tensions between the needs of employers and the capacity of HCPs to provide tailored workplace advice. Consequently, alongside extending fit note certification to a wider range of HCPs, it appears important to ensure that employers have access to specialist OH services.

1.3.5 Chapter Seven: Returning to work

There was mixed evidence of planned and cooperative return to work processes between individuals and their employer across the interviews. When this was successfully done, employers and patients often spoke about the quality and timeliness of the contact during the sickness absence, and the importance of both parties working together to plan for returns to work. Less positive experiences of return to work appeared to frequently be the result of poor communication between the employee and their employer during periods of sickness absence. Poor communication occurred when employers lacked awareness of how to effectively manage returns to work. This often led to a lack of shared understanding between the employee and their employer about how workplace adjustments could be best implemented to support returns to work.

1.3.6 Chapter Eight: Summary and recommendations

This research indicates that the extension of fit note certification powers to a wider range of appropriate HCPs is likely to be well received by HCPs, employers and patients. The findings indicate a range of potential benefits to extending fit note certification including:

Enabling more detailed and tailored workplace advice to be provided to both patients and their employers.
Reducing current time and workload pressures on GPs.
Minimising duplications in effort and resources in the current fit note process.
Ensuring more effective use of professional healthcare time and NHS resources.
Providing a better ‘fit note experience’ for patients, employers and healthcare professionals.

Overall, the research also highlights broad consensus between patients, employers and HCPs regarding the qualifications, skills and experience needed to issue fit notes. These include the necessity for HCPs to operate at an advanced level, to be registered and licensed to practise clinically, and to have received relevant training on how to assess fitness for work and complete and issue fit notes.

Despite this positive reception, a number of challenges to the successful delivery and implementation of the extension have been identified, including:

Identifying the right HCPs with the skills, competencies and experiences to certify the fit note.
Poor accessibility of patient clinical records for HCPs other than GPs.
Preventing HCPs assessing and issuing fit notes outside of their clinical practice or skillset.
The discord between the level of detail employers expect from a fit note, the type of workplace advice that HCPs are able and required to offer and the role of wider occupational health services.

These findings raise several important recommendations that could enhance the delivery of the fit note, better standardise processes, and support the effective implementation of the policy.

Question 6

2.  Introduction

Accepted Answer

2.1 Policy background

Employers, Health and Inclusive Employment directorate (EHIE) is a UK government unit which brings together officials from the Department for Work and Pensions (DWP) and the Department of Health and Social Care (DHSC) to lead the government’s strategy in supporting working-age disabled people, and people with long-term health conditions to enter, and stay in, employment. Good quality work^{[footnote 11]} has been shown to generally have a positive impact on the health and wellbeing of individuals, their families and their communities.^{[footnote 12]} This has led to growing awareness that long-term unemployment due to sickness absence can have a harmful impact on an individual’s physical and mental health over time.^{[footnote 13]}

In 2017, the Improving Lives: The Future of Work, Health and Disability Paper^{[footnote 14]} announced the government’s commitment to extend fit note certification powers beyond GPs and hospital doctors to a wider range of HCPs, such as advanced nurse practitioners, occupational health nurses, occupational therapists, mental health professionals, pharmacists and physiotherapists. This commitment emerged from an earlier consultation with key stakeholders which had indicated that changes to fit note certification powers had the potential to reduce clinical and administrative burdens on GPs, improve the quality of health and work conversations, and support the NHS multi-disciplinary approach to patient-focused clinical care.

Currently, fit notes are issued by either a GP or hospital doctor when an individual’s health condition has impacted on their fitness for work. The provision of a fit note involves an assessment of an individual’s fitness for work by either a GP or hospital doctors but can, on occasions, be also based on a report written by another healthcare professional such as an Advanced Nurse Practitioner. Assessments determine whether an individual is either ‘not fit for any work’ or ‘may be fit for work’ if certain workplace adjustments are in place. Therefore, fit notes which indicate that an individual ‘may be fit for work’ intend to offer potential workplace adjustments, such as phased returns to work, amended duties, altered hours or workplace adjustments, which may support individuals with a health condition to remain in or return to employment.

However, despite fit notes providing GPs and hospital doctors with the option to assess an individual as ‘may be fit for work’ since 2010, published fit note data extracted from anonymised NHS GP practices across England indicates that relatively few fit notes assess an individual as ‘may be fit for work’ and recommend workplace adjustments. In 2018/19, only 6.9%^{[footnote 15]} of fit notes indicated that an individual ‘may be fit for work’ and offered workplace advice. As a result, many individuals with a health condition currently may not be benefiting from work place adjustments that may support them to return to or remain in employment.

The WHU is currently working alongside stakeholders, including healthcare professionals, representatives of Royal Colleges and policy experts, to develop the necessary policy and legislative changes to extend fit note certification powers to a wider range of healthcare professionals. The findings from this report aim to support the successful development and implementation of this fit note legislative reform.

2.2 Research aims

This research study explores the experiences and views of patients, employers and HCPs of the current fit note process and examines their perceptions and attitudes towards extension of fit note certification to a range of different HCPs. In particular, this research aims to:

Explore the different motivations and expectations around the use of the fit note
Explore whether fit notes currently meet the needs of HCPs, employers and patients
Identify key issues to address prior to the implementation of legislative and policy reform
Identify key messages which will raise awareness of legislative and policy reforms amongst HCPs, employers and patients
Explore the forms of training, education and skills required to ensure the successful implementation and delivery of legislative and policy reform
Explore whether extending the certification of fit notes to a wider range of HCPs will improve health and work conversations

2.3 Method

Between 23 April and 12 June 2019, Ipsos MORI conducted a total of 68 in-depth telephone interviews with patients, employers, general practitioners (GPs), advanced nurse practitioners (ANPs) and other HCPs (see Table 2.1 for a detailed breakdown of recruitment).

Table 2.1: Number of interviews completed by participant group

Groups	Completed interviews
GPs	10
ANPs	10
Other HCPs	10
Employers who have experienced fit notes	17
Employers who have not experienced fit notes	6
Patients	15
Total	68

To capture a range of different experiences and perceptions towards the current fit note process and proposed legislative reform, recruitment for this study was undertaken across Great Britain and from a range of different urban and rural localities. In particular, recruitment focused on obtaining the following from the different participant groups:

Employers:

Employers from different industry sectors with varying numbers of permanent employees working in both manual and office-based environments^{[footnote 16]}
Employers working at different levels of an organisation, such as line managers, business owners and HR staff
Employers who had both prior and no experience of receiving fit notes from their employees

HCPs:

HCPs, including ANPs, working across the NHS who currently support the fit note assessment process, and GPs who currently assess fitness for work and issue fit notes
HCPs anticipated to be best placed to certify fit notes in the future, including specialist nurses working in OH, physiotherapists, occupational therapists, pharmacists and mental health professionals (please see the appendix for a further breakdown of recruited HCPs)

Patients:

Patients with experience of a physical or mental health condition who received a fit note while in employment^{[footnote 17]}
Patients with experience of either ‘not fit for work’ or ‘maybe fit for work’ fit notes
Patients working in both manual and office-based environments

Please see the Appendix for the full quota table and detailed methodology.

2.4 Interpretation and representation of qualitative data

Qualitative approaches explore the nuances and diversity of views and experiences, the factors which shape or underlie them, and the ideas and situations that can lead views to change. In doing so, it provides insight into a range of views that, although not statistically representative, nonetheless offer important insight into overarching themes.

Verbatim quotes have been included in this report to illustrate and highlight key points and common themes. Where verbatim quotes are used, they have been anonymised and attributed according to key characteristics of the participants, i.e. employment sector and size, healthcare condition and type of healthcare profession.

2.5 Structure and presentation of the report

The report is structured as follows:

‘Chapter 3: The fit note in context’ explores the wider context in which the fit note process is embedded. It examines the relationship between work and health and responsibilities for promoting, maintaining and supporting health and wellbeing at work. The discussions then move on to explore a number of the alternative forms of medical evidence that are often currently provided either alongside, and sometimes instead of, fit notes to in-work individuals by HCPs.
‘Chapter 4: Views on fit note extension’ explores the views of HCPs, employers and patients to extending fit note certification powers. These discussions highlight the potential benefits and risks associated with extension, as well as ways in which these risks can potentially be mitigated during policy implementation. This chapter also identifies the types of qualifications, skills and experience which the majority of participants agreed that HCPs must possess in order to appropriately assess and issue fit notes.
‘Chapter 5: Assessing fitness for work’ examines how GPs and ANPs currently conduct work and health conversations and assess fitness for work. This provides insight into some of the challenges faced and the ways in which these are currently negotiated by many of the GPs and ANPs involved in this study.
‘Chapter 6: Views on the ‘may be fit for work’ option’ explores some of the benefits and challenges presented when GPs and ANPs assess an individual as ‘may be fit for work’. This is followed by a discussion of potential ways to encourage wider use of ‘may be fit for work’ fit notes in the future and ways in which to encourage their further use in the future.
‘Chapter 7: Returning to work’ explores what happens when employees returned to work following sickness absence, including any conversations they had with their GP, other HCP or employer.
‘Chapter 8: Summary and implications’ summarises the findings and insights of this report and provides a number of broader implications and practical recommendations to support future policy development and implementation.

2.6 Terminology used throughout the report

Throughout this report, the key participant groups will be referred to as follows:

Patients/employees will be used interchangeably, with ‘patients’ used when discussing their relationship to HCPs, and ‘employees’ when discussing their relationships with employers.
Employers who have received a fit note refers to those who have experience of receiving a fit note from their employees.
Employers who have not received a fit note are those who do not have experience of receiving a fit note from their employees.
HCPs will be used to speak about HCPs generally, while GPs and ANPs will be used when discussing fitness for work assessments prior to issuing a fit note

Question 7

3.  The fit note in context

Accepted Answer

This chapter explores the context in which the fit note process is embedded. It first examines the ways in which the different participant groups understood the relationship between work and health and their attitudes towards who should assume responsibility for promoting, supporting and maintaining the health and wellbeing of individuals in employment. The discussions then move on to explore a number of alternative forms of medical evidence provided by HCPs to in-work individuals either alongside, and sometimes instead of, fit notes. The discussions in this chapter provide a context for understanding later explorations of participants’ perceptions of the current fit note process and the proposal to extend fit note certification powers to a wider range of HCPs in the future.

3.1 Exploring the relationship between work and health

All of the participant groups recognised that good quality work could impact positively on an individual’s health and wellbeing, particularly their mental health. Work was seen to provide structure, routine and a purpose to the day, to enable socialisation and interaction with work colleagues, and to offer individuals financial security.

Work is fundamental to wellbeing. Work means you have a role in society, a reason to get up in the morning and be motivated. It gives you that routine, which is so healthy.

(General practitioner)

My mental health suffered for being off that length of time [six weeks], even though it was something physical. It was very difficult to structure my day, and to fill it, apart from sitting on the sofa and eating biscuits… I was incredibly keen to go back to work. The option was there for me to have four months off work, but I wouldn’t have been able to cope with that!

(Patient, physical health condition, mostly manual work)

Many of the HCPs described how employment could promote and maintain the physical and mental health of their patients. They often noted the detrimental impact that long-term sickness absences, usually six months or more, could have on an individual’s likelihood of returning to work in the future. The impact of long-term sickness absences was similarly noted by many of the GPs and ANPs who frequently reported that patients in employment appeared to present less in their clinics than those who were unemployed or unable to work due to their health conditions. Individuals in employment appeared to many of the GPs and ANPs to have, in general, a better standard of living, with work often mentioned to contribute to an individual’s good health by providing the financial means for a healthier lifestyle, such as enabling people to eat healthily, have more active lifestyles and afford social activities.

From our experience, as soon as people are out of work, if it goes on for longer than a few months, it’s extremely difficult to get people back in, and work is crucial to wellbeing. Loss of work is a disaster really. It can exacerbate, or cause, mental health issues. It causes major income problems, it causes a downward drift whereby they can lose one thing and then another – relationships, their accommodation – it’s a key component of any kind of spiral into decline for many individuals that we see on long-term sick.

(General practitioner)

Employers and employees also acknowledged the importance of positive workplace culture in fostering an environment conducive to good health and wellbeing, both physical and mental. A positive work culture was described by many to be one in which employees were engaged in their work, found their workload manageable and where employers took an active role in supporting their employees to maintain their health and wellbeing so they continued to have the capacity to carry out their job role.

A good work environment with a good team can be really beneficial from a mental health and wellbeing perspective, conversely a highly charged and stressful environment without a supportive team is very damaging.

(Employer with experience of fit notes, 2-9 employees, no HR function)

As a result, all of the participant groups explained that being overstretched or under sustained pressure at work had the potential to negatively impact on an individual’s health and wellbeing, and it was recognised that this may, in some cases, lead to work-related stress or anxiety. For the majority of employers and employees, workplace culture was therefore an important factor in mediating the impact of workplace pressures on individual health and wellbeing. Many of the employees, for example, explained that, even if they had a heavy workload or felt under pressure at work, if they had the support of their employer, it would likely have less of an impact on their overall health and wellbeing. Significantly for this report, employees who described their employers reacting negatively to their periods of ill-health in the workplace or sickness absence tended to place greater importance on the role of employers in mediating the relationship between work and wellbeing and often had clear ideas and perceptions of what their employer should do when managing sickness absence.

There was broad agreement across all of the participant groups that a wide pool of actors was involved in supporting an individual’s health and wellbeing. Whilst most of the participants did not indicate that any one individual or group had sole responsibility, it was frequently emphasised that employers, HCPs as well as the individual in poor health all have a critical role in promoting, supporting and maintaining health and wellbeing at work.

Individuals in poor health, for instance, were often expected to actively seek help from HCPs and alert their employers when they became unwell so that both parties could provide appropriate support. Employers, on the other hand, were often seen to be responsible for both ensuring basic health and safety standards were met in the workplace and fostering a supportive and open workplace environment. Many of the larger employers explained that having awareness of their responsibilities led them to offer their employees formal health and wellbeing strategies, such as providing access to occupational health or counselling services. Similarly, smaller employers explained that they tried to support all their employees by creating close relationships with their staff and fostering a tight-knit ‘family’ environment.

In this study, work was therefore indicated by all groups of participants as having a considerable impact on an individual’s overall health and wellbeing.

3.2 Other forms of medical evidence

Over the course of the study, it became clear that some HCPs, such as pharmacists, occupational therapists, physiotherapists and ANPs, can also provide forms of medical evidence about an individual’s health condition to both GPs and employers (Figure 3.1). These alternative forms of medical evidence were described by a number of HCPs as providing additional support, and also further enhancing, the current fit note process.

Figure 3.1 Alternative forms of medical evidence:

AHP Health and Work Report

AHPs assessing fitness for work and sent direct to employers. Could give more detail, as conducted by specialists.

Patient Care Reference in Scotland

Online document sent direct to GPs, providing details of patient consultations with pharmacists (Scotland only).

AHPs’ reports to GPs

GPs can issue fit notes on the basis of another HCP’s assessment of the patient, for example if they have a relations or are treating them for a condition.

Attendance slips

From walk-in centres to provide proof to employers that employees have sought medical help during the self-certification period.

In some cases, these alternative forms of medical evidence had arisen as a way to mediate the current fit note process. For example, one ANP described how staff at a walk-in centre had started to provide ‘attendance slips’ to patients who requested a fit note to cover the seven-day self-certification period. The need for such ‘attendance slips’ was often due to patients and employers not being aware of the self-certification period or employers expecting to see medical evidence of illness and patients having difficulties getting timely appointments with their GPs. In these incidences, ‘attendance slips’ were seen as a way to provide patients with short-term medical evidence for employers until they could be assessed by their GP.

We don’t do fit notes here, so I would refer them to their GP if I felt they needed an extended period off work. We’ve started providing slips for patients, so they can show to their employers that they’ve had an appointment, if they can’t see their GP.

(Advanced nurse practitioner)

In other cases, alternative forms of medical evidence had developed as a way for AHPs to demonstrate their capacity to assess fitness for work and certify fit notes. For example, a number of HCPs emphasised during the study how the AHP Advisory Work and Health Report^{[footnote 18]} enabled specialist HCPs, such as physiotherapists, to provide workplace advice to individual’s with physical and mental health conditions. The provision of the report was, therefore, often described as a way in which some HCPs could currently support GPs and also employers to better understand the types of practical modifications that may help an individual to remain engaged in or return to work.

Our fit note [sic – AHP Work and Health Report] tries to get people back to work, while the GP’s fit note is more about signing off from work. For example, ‘So and so’ has a troublesome knee, it’s swelling up quite a lot if they are standing, so we would suggest that they do afternoon shifts because that is when their symptoms are better, or something like that… but it’s not binding, so the employer doesn’t have to take it into account.

(Physiotherapist)

Importantly for this study, many of the HCPs involved in the research considered that the AHP Health and Work Reports provided employers with more specific and detailed advice about the nature of an individual’s health condition and the implications for their job role. As a result, the vast majority of AHPs who had experience of issuing AHP Health and Work Reports expressed interest and enthusiasm in the extension of fit note certification to a wider range of HCPs.

Question 8

4.  Views on fit note extension

Accepted Answer

This chapter explores the views of HCPs, employers and patients towards extending fit note certification powers to a wider range of HCPs. First, this section highlights the potential benefits and risks that participants perceived to be associated with fit note extension. Second, it considers the ways in which participants suggested these risks could be mitigated. Finally, it explores the types of qualifications, skills and experiences that different participant groups expected HCPs to possess in order to be able to issue appropriate and effective fit notes.

4.1 Benefits of extending fit note certification

4.1.1 Detailed and specialist advice

All of the participant groups had similar views on the potential benefits of extending fit note certification powers to a wider range of HCPs. Many of the participants, for instance, explained that extending fit note certification had the potential to ensure that fit notes provided more appropriate and timely health and work advice from HCPs with a clear understanding of an individual’s fitness for work, and prevent the need for patients to make separate appointments with their GP, who was likely to have more limited involvement and understanding of their health condition.

Ideally a fit note would be issued by someone who is actively helping them overcome their illness and return to work.

(Pharmacist)

Continuity of care was expected to build a positive rapport between the patient and the HCP providing the fit note, and also ensure that the patient did not have to continually justify, revisit or explain their health condition or symptoms. The potential for the extension of fit note certification powers to eliminate the need for separate GP appointments was, therefore, anticipated by some of the participants to reduce the level of stress and anxiety experienced by some patients, particularly those with mental health conditions.

Extending the range of HCPs able to issue fit notes was also expected by all of the participant groups to lead to the provision of more detailed and tailored workplace advice on fit notes. Many of the participants mentioned that fit notes currently issued by GPs often offered only broad, and at times vague, workplace advice because GPs do not always have the time or specialist knowledge to accurately assess how a patient’s health condition may impact on their capacity to work. As a result, it was thought that enabling HCPs more closely involved in the ongoing care of a patient or who specialised in particular areas of health (e.g. mental health) could offer specific and realistic workplace advice that would better support more individuals to remain in or return to work.

It’s definitely, from an employer’s perspective, a positive. I think I would like to see more interaction between the employers and the health professionals to be able to facilitate people back into the workplace.

(Employer with experience of fit notes, 250+ employees, HR function, mix of manual and office-based work)

As a result, it was expected by many of the participants that the proposal to extend fit note certification powers would reduce the number of fit notes that assessed an individual as not fit for work and, in doing so, prevent unnecessary and prolonged sickness absences from work.

4.1.2 Less pressure on GPs

All of the participant groups indicated that the extension of fit note certification would likely have a positive impact on GPs by both saving GPs’ time and reducing their current workload. This alleviation of workload pressures was anticipated by many of the participants to lead to increased GP appointment availability, particularly for those patients with complex needs who may need emergency appointments.

The capacity for the extension of fit note certification powers to reduce time and workload pressures on GPs was particularly noted by those ANPs in this study who currently carry out the vast majority of fit note assessments in their practice and only require GPs to sign the fit note itself. These practitioners often described how the current fit note system was an inefficient use of their time and meant additional pressures on doctors who are already time-pressured and, therefore, they often reported that having the capacity to certify fit notes would both avoid duplication of work and reinforce their credentials as qualified medical professionals.

It would make my job a lot easier. It would certainly save me a lot of time. I wouldn’t have to keep sprinting out my room every half an hour or so to find a doctor to sign a fit note for me. It just makes you feel like you’re doing a complete job for the patient.

(Advanced nurse practitioner)

Consequently, having the capacity to assess and certify fit notes was described by many of the HCPs in this research study as having the potential to both bust societal myths about their ‘inferior’ position to doctors and provide important cost savings to the NHS.

4.1.3 Reduced instances of fit note misuse

All of the participant groups noted that the extension of fit note certification powers to a wider range of HCPs could reduce instances of fit note misuse. They spoke about how specialist HCPs were in a better position to assess the impact of an individual’s health condition on their fitness for work and, therefore, potentially more able to positively challenge patients’ perceptions of the implications of their poor health. Specialist HCPs, particularly those working within an OH remit or issuing other forms of medical evidence, were seen as better placed to assess how a patient’s health condition linked to their workplace functionality. These specialist HCPs would potentially be more confident, and therefore able, to state that a patient does not need to be certified as unfit to work and instead more effectively use the ‘may be fit for work’ option, ensuring employees can stay in work or return to work successfully. In addition, the unique skillset often held by HCPs with an OH remit would ensure they are well placed to sensitively challenge patients who want but may not need time off work.

4.2 Perceived risks associated with extension

4.2.1 Qualifications and regulation of HCPs

When prompted to think about some of the risks associated with fit note extension, a number of the employers and patients contemplated whether some HCPs may not be as medically qualified or professionally regulated as GPs and hospital doctors. Often this appeared to arise from a general lack of understanding by some employers and patients of the roles and qualifications of certain HCPs as well as reflecting greater familiarity with the roles and remit of GPs. In these cases, employers expressed concern that there would continue to be considerable reliance on GPs.

What’s to stop my physio friend going ‘yeah I’ll write you a sick note!’ You do that to a GP and they can be struck off. What’s the comeback on physios?

(Employer with experience of fit notes, 50-249 employees, HR function, mostly manual work)

These perceptions were echoed across many of the interviews with HCPs, with a number expressing concern that some employers may only recognise or value a fit note issued by a GP. This led to some concern that some employers and patients may potentially disregard or refuse to accept workplace advice provided by other HCPs. Such perceptions and attitudes were believed by many of the HCPs to be increasingly likely if the employer had an out-dated hierarchical view of HCPs, for example a doctor was more skilled and better placed than an ANP. However, these employers generally had limited knowledge and experience of interacting with different healthcare professionals and / or did not have access to HR or occupational health departments.

As a result, all of the participant groups emphasised the need for effective communication, information and a publicity campaign for HCPs, patients and employers which addressed popular misperceptions and recommended that information about the fit note extension and the suitability of particular HCPs to certify fit notes is disseminated through marketing materials, such as posters, emails and online adverts.

4.2.2 Clinical areas of expertise

One concern that many of the employers expressed about the extension of fit note certification to a wider range of HCPs was the potential that HCPs may be able to issue fit notes for areas unrelated to their specialism. For example, a physiotherapist assessing and providing advice about how an individual’s mental health condition impacts on their fitness to work.

I think if it’s a physiotherapist that’s able to issue a fit note, it should be in that field, because in terms of a mental health condition, how would they know enough about the condition to make that, sort of, judgement… I think that would put a lot of things into question.

(Medium sized employer with experience of fit notes, HR function, mix of manual and office-based work)

Many of the HCPs, therefore, emphasised the need for a comprehensive training programme that covers the relationship between health and work, the specifics of the fit note process and also relevant areas of employment law. Training on employment policies and practices was deemed to be particularly important for HCPs in order to fully understand the patient’s work tasks and be able to comment on the functional effects of their health condition. Similarly, training that covered ‘good practice’ guidelines on how to conduct assessments was also reported as important to help ensure consistency in the ways in which fitness to work is assessed. For those HCPs who already had experience of providing fit notes, it was suggested that training should also cover how to manage difficult situations, such as when a patient does not agree with a practitioner’s assessment of their fitness for work. Training in this area was anticipated to help protect the ‘doctor-patient’ relationship and ensure that patients are provided the best possible care whilst also enabling practitioners to protect their own health and wellbeing at work. Awareness of the complexities around assessments of fitness to work and challenges presented by some patients led a number of HCPs to suggest that ongoing supervision and mentoring would help to monitor and reinforce ‘good practice’.

4.2.3 Fragmented communication

Another concern reported by all of the participant groups was the current lack of a centralised clinical record system. While it was widely recognised that there is a move towards improving and integrating different clinical systems in the NHS, a number of participants highlighted that some HCPs do not always have access to a patient’s full clinical records. As a result, they explained that these HCPs may not be able to gain a holistic picture of the patient’s medical history and be able to ascertain when, if and why a fit note has previously been issued or denied. Some participants were concerned that this may lead some patients to receive multiple fit notes from different HCPs advising conflicting workplace adjustments, for example, a patient with both physical and mental health conditions may potentially be able to receive a fit note from multiple specialists involved in their treatment. This raised the issue of which healthcare professional, in these cases, should issue the fit note, as well as the need for clear guidance on how these situations should be managed.

Poor access to clinical records was also seen as having the potential to lead a minority of patients to ‘shop’ between different HCPs until they receive the fit note desired. The ‘shopping’ around for fit notes was noted by some of the participants to have the potential to increase time and workload pressures on HCPs.

You could get a patient shopping around a pharmacist, physiotherapist or GP until they found the one that kept them off work the longest.

(Occupational therapist)

Employers who expressed concern about individuals ‘shopping’ around for fit notes also thought that it may lead to longer periods of time off work than was necessarily required. HCPs explained that an improved NHS IT infrastructure could potentially mitigate these risks by ensuring that more HCPs have access to patient clinical records. Many, nonetheless, recognised that improving the NHS IT system would require considerable overhaul and recognised that this was likely beyond the scope of the proposed fit note extension. As a result, other smaller changes were suggested such as making electronic fit notes mandatory and phasing out paper-based fit notes. Standardised digital fit notes were seen to offer a better record of the fit notes issued to patients because they could be more easily audited and accessed to help detect any potential misuses. An alternative suggested approach was to establish mandatory sections within the fit note template which have, where applicable, tick boxes and drop-down boxes offering standardised responses for consistency. At a basic level this was thought to mitigate vague information that was sometimes reported to be provided by GPs on fit notes and make it easier to provide more specific information. The more specific and detailed the information, the harder it was seen to be to potentially misuse or dismiss the fit note.

4.2.4 Burden on HCPs

During the study, a number of the GPs expressed concern that extending fit note certification to a wider range of HCPs could potentially increase the workload of these practitioners. They explained that, because many HCPs already had to manage significant workloads, some may not be interested in assuming additional responsibilities. However, this was not a concern shared by the majority of practitioners who already assumed responsibility for the assessment, diagnosis and treatment of patients within their day to day role. For these individuals, having the added responsibility to certify fit notes was not expected to impact substantially on their existing clinical or administrative roles. If anything, it was considered that this would lead to a more efficient use of their time.

However, a number of the HCPs who had limited experience of having conversations about work and health did express some concern that patients, particularly those used to GPs providing fit notes, may not accept a fit note which they had certified. For these HCPs, having responsibility to certify fit notes was often described as having the potential to lead to increasingly confrontational and less treatment-focused relationships with their patients.

My concern is whether [fit note extension] changes the dynamic and relationship between you and the patient. At the minute that’s all kept quite distant because the GPs will say if someone’s signed off or not. The only concern is whether that changes the therapeutic relationship because you have more power over what you’re expecting people to do, and whether it increases demand in people wanting to get fit notes rather than engage with their therapy.

(Physiotherapist)

For this reason, a number of the HCPs suggested that extension of fit note certification should be first implemented as a pilot in order to ensure timely audits, sufficient evidence of what is working and what is working less well, and to enable a process and impact evaluation to be conducted. These feedback mechanisms were emphasised by a number of HCPs to be critical to the successful implementation of the fit note extension as they would enable HCPs to flag any challenges and barriers prior to its rollout.

4.3 HCPs with the skills and expertise to issue fit notes

Over the course of the study patients, employers and HCPs were all asked to identify the types of qualifications, skills and experience HCPs needed to appropriately assess and issue fit notes. Across all of the participant groups, there appeared to be a general consensus that HCPs providing fit notes should operate at an advanced level, be registered and licensed to practise, and also have received training on issuing fit notes. In contrast, HCPs deemed not to have the appropriate qualifications, skills and experience to issue fit notes tended to be in roles which had less regular contact with patients, did not require registration with medical professional bodies, and often had limited autonomy to diagnose, treat and prescribe (see Figure 4.3. for a summary of the types of HCPs considered to have, or not to have, suitable qualifications, skills and experience to issue fit notes).

Figure 4.3 Healthcare professions viewed as having the qualifications, skills and experience to issue fit notes

Well placed

GPs and ANPs
Mental Health Professionals and Psychiatrists
Occupational Health Professionals
Physiotherapists
Surgeons and Dentists
Social Workers with clinical qualifications

Mixed views

Pharmacists
Paramedics

Not well placed

Health care assistants
Walk-in centre HCPs
Practice nurses
Pharmacy dispensers
Chiropractors
Reception staff

Despite this general agreement between all of the different participant groups regarding which HCPs should and should not issue fit notes, there were, however, a few instances when patients, employers and different HCPs had mixed or opposing views.

4.3.1 Views of patients

On the whole, the patients interviewed did not express strong views to suggest that they felt that certain HCPs may not have the appropriate qualifications, skills or experience to issue a fit note. However, when they were asked during the interview whether there were any HCP roles that they perhaps may be less comfortable accepting a fit note from, a number suggested the following: nurses without the relevant experience, midwives, healthcare assistants, pharmacists, chemists and receptionists. These roles were regarded by some patients as inappropriate to issue fit notes because either they were not perceived as practising at an advanced level, in relation to their training, experience and seniority, or were seen as unlikely to be involved with patients who had health conditions that may require time off work. As a result, these HCPs were viewed as not having the appropriate skills to assess fitness for work, or to adequately understand the relationship between health and work.

4.3.2 Views of employers

The vast majority of employers emphasised the need for HCPs issuing fit notes to have suitable medical credentials (such as practicing at an advanced level) as well as softer skills, such as the ability to listen, to ask the ‘right’ questions to effectively assess fitness for work and provide realistic and pragmatic workplace advice. Most employers, therefore, explained that it is important that any HCP issuing a fit note has an awareness of the patient’s clinical history, is involved in any ongoing treatment plans, and has enough time to adequately assess the impact of a patient’s health condition on their fitness for work, as well as provide advice on tailored workplace adaptations.

During the interview, employers were also prompted to think about the suitability of extending fit note certification powers to five particular healthcare professional roles: ANPs, specialist nurses in occupational health, physiotherapists, occupational therapists, pharmacists and mental health professionals. For the majority of these healthcare professions, employers tended to accept that these roles already had the appropriate skills and competencies to issue fit notes, or could be trained to achieve such skills and competencies in the future. Interestingly, these discussions appeared to help some of the employers to think about other types of healthcare professions they would consider to have the capacity to assess fitness for work. As a result, both hospital consultants and paramedics who had regular contact with a patient were mentioned as potentially having the skills, capacity and experience to provide fit notes for some patients.

As long as they are medically trained to be able to assess one of our employees and providing the right treatment, then who am I to argue?

(Employer with experience of fit notes, 250+ employees, HR function, manual and office based)

Some of the employers were nonetheless hesitant about the suitability of pharmacists to assess and issue fit notes. Often this appeared to be because employers were unclear about the role and remit of pharmacists and, therefore, uncertain whether they had the appropriate credentials and holistic overview of a patient’s health condition. As a result, some of the employers suggested that pharmacists would be less able to suitably assess a patient’s fitness for work and may therefore, in some cases, be more easily persuaded by patients to provide an inappropriate fit note.

I know pharmacists are very clued up and very helpful, but anybody… Joe Bloggs could go down the road to see a pharmacist and say ‘I’ve got this that and everything else’. They do prescriptions but I don’t see how they could do a fit note properly. Anybody could fob off a pharmacist.

(Employer with experience of fit notes, 2-9 employees, no HR function, mostly manual work)

4.3.3 Views of GPs and ANPs

All of the GPs and ANPs emphasised the need for HCPs issuing fit notes to work at an advanced level and to have considerable medical knowledge and experience of working with, and making decisions about, a patient’s health condition. In addition, they explained that HCPs certifying fit notes should have adequate knowledge about different employment practices, such as health and safety regulations, as well as an understanding of a patient’s job role so that they are able to assess the impact of a patient’s health condition on their fitness for work. GPs and ANPs, therefore, did not necessarily believe that HCPs would need the same level of medical knowledge and training as GPs but should be upskilled to understand the relationship between health and work. Moreover, it was essential to GPs and ANPs that HCPs should only be able to issue fit notes within their clinical remit to ensure that they were completed accurately. It was nonetheless suggested by many GPs and ANPs that HCPs issuing fit notes should have a broad understanding of mental health issues because many physical health conditions are noted to be associated with mental health conditions.

I think you need a professional who has got some medical knowledge behind them and also some work and employment knowledge behind them, so they’re masters in both fields, so they can make an assessment, make a judgement, and deliver that to the patient and their decision is final.

(General practitioner)

As with employers, GPs and ANPs were prompted to think about the suitability of extending fit note certification powers to five particular healthcare professional roles: ANPs, specialist nurses in occupational health, physiotherapists, occupational therapists, pharmacists and mental health professionals. Echoing the views of the employer group, GPs and ANPs thought that all of these different healthcare roles, besides pharmacists, would have the appropriate medical credentials, knowledge and experience to issue fit notes. Similar to employers, these discussions led many of the GPs and ANPs to provide other, unprompted, HCPs roles which they believed had the relevant qualifications, skills and experience to issue fit notes. These included dentists, opticians, senior social workers with a clinical qualification and palliative care teams where the patient was of working age.^{[footnote 19]} Social workers with a clinical qualification were deemed to have the personal, ongoing contact with patients as well as having some medical training.

On the whole, pharmacists were again seen to be healthcare profession roles that did not have the capacity, experience or remit to assess fitness for work. GPs and ANPs often noted that pharmacists generally did not appear to have either the time or to work in a context that would enable them to effectively assess fitness for work, and that this was compounded by their poor access to patient clinical records and lack of appropriate training. As a result, only a number of the GPs and ANPs accepted that some senior pharmacists whose role involved ongoing relationships with patients would likely have relevant skills and experience to issue fit notes.

These discussions about the suitability of pharmacists to provide fit notes led some GPs and ANPs to also describe their uncertainty about whether other healthcare professions, such as healthcare assistants and nurses not working to an advanced level, receptionists, phlebotomists or walk-in centre HCPs, would similarly not have the relevant competencies and experience to assess a patient’s fitness for work. While some debated that these healthcare professionals could be trained to issue fit notes, others believed they did not have the underlying depth of medical knowledge and competencies required.

4.3.4 Views of HCPs

In general, the views of the various mental health professionals, pharmacists, physiotherapists, occupational health nurses, and occupational therapists interviewed reflected those of the GPs and advanced nurse practitioners. Most commented that HCPs issuing fit notes would need to be skilled in investigating, assessing, diagnosing and communicating the implications of an individual’s health condition. To ensure this was the case, the majority suggested that HCPs providing fit notes would need to be working in a senior position and have relevant experience of working closely with patients. Limiting the scope of HCPs in this way was expected to ensure that only HCPs with the confidence and competency to determine fitness for work would be able to certify fit notes.

As with the other participant groups, these different HCPs also accepted that ANPs, specialist nurses in occupational health, physiotherapists, occupational therapists, and mental health professionals were well suited to provide fit notes. The capacity and competency of pharmacists to assess fitness for work was, therefore, again questioned. Similar to the discussions with GPs and ANPs, the inability of pharmacists to access patient clinical records when working outside of a GP practice was noted by some of the HCPs to have potentially detrimental implications for the capacity to appropriately assess a patient’s capacity for work. Interestingly, this concern was also echoed by one of the pharmacists interviewed who suggested that not having a thorough understanding of the patient’s health condition had the potential to result in the provision of inappropriate workplace advice and to even, at times, lead some patients to try to request fit notes from different pharmacists until the workplace advice best suited their needs. These discussions led a number of these HCPs to comment that social workers with a health qualification, specialist nurses and speech and language therapists may be better suited to issue fit notes because they are likely to work at an advanced level, have specialist health knowledge and be closely involved in patient care.

Question 9

5.  Assessing fitness for work

Accepted Answer

The discussions so far have explored the various benefits and risks associated with the extension of fit note certification powers to a wider range of HCPs as identified by the different participant groups involved in this study. In addition, it has explored the various qualifications, skills and experience that the different participant groups consider important to ensure that fitness for work and fit notes are issued appropriately. Many of these findings reflect the varying benefits and challenges that patients, employers and HCPs confront when negotiating the current fit note system. The remainder of this report, therefore, seeks to highlight some of the key areas of the current fit notes system as identified by the participants involved in this study, and examine the extent to which extending fit note certification powers will help to support patients, employers and different HCPs to remain in or return to employment. This chapter explores the circumstances that often surround the provision of a fit note by GPs and hospital doctors, and offers an in-depth examination of how an individual’s fitness for work is currently assessed.

5.1 Circumstances that lead to a fit note being issued

Over the course of the study, six different circumstances when a fit note would be issued were identified through discussions with GPs and ANPs.

Self-certification

These are cases when an individual is either unaware of their capacity to self-certify for up to 7 consecutive days or an employer is sceptical that their employee is unfit for work. In this study, GPs and ANPs often explained that both individuals and employers often wanted a fit note as proof of their health condition or illness, and described how this appeared to stem from a lack of trust between many employers and their employees. As a result, many of the GPs and ANPs involved in this research study reported that a considerable number of such appointments are unnecessary, leading to some examples of practices charging for fit notes during this self-certification period.

Requesters

These are patients who book an appointment to specifically request a fit note rather than primarily to discuss a health condition. The need for a fit note is, therefore, often presented at the start of the consultation.

In these cases, the GPs and ANPs involved in the study explained how they would try to sensitively understand the patient’s desire for a fit note by asking questions about their health and its impact on their capacity to remain in employment. This was described by the vast majority as being particularly important when a patient is adamant that they need a fit note in order to ensure that the patient does not feel unheard or mistrusted. Having conversations about work and health was, consequently, quite a delicate process with some of the patients requesting fit notes, with considerable emphasis placed on the need to create working relationships with these patients in the short and longer term.

Long-term sickness absences

These are cases when a patient is already in receipt of a ‘not fit for work’ fit note and, therefore, is not anticipated to return to work in the near future.

Patients in receipt of a long-term fit note may require either regular or ‘as necessary’ re-assessments with their GP. In these cases, the need for a fit note often tends to drive the assessment of the patient, with GPs and ANPs seeking to understand the extent to which the patient’s health has improved, their levels of engagement with their treatment plan, as well as assessments of their overall fitness for work. However, for cases over six months, the GPs and ANPs in this study indicated that there was little they could realistically offer during re-assessments to help their patients to return to work. Many explained that responsibility for the patient’s longer term work prospects at this point often shifted to the benefit system because an individual’s capacity to return to work depended on their benefit entitlements, the provision of training and volunteering opportunities as well as appropriate workplace support.

Unknown conditions

This is when a patient books a medical appointment to discuss symptoms arising from an undiagnosed health issue. As the focus of the consultation is on their health, these patients often do not initiate conversations about the need for a fit note but fit notes are often provided once the HCP has gained a holistic picture of the patient’s health and its impact on their fitness for work.

The assessment by HCPs that a patient is not fit for work in these circumstances often leads to the following responses from individuals:

Resistance to taking time off work – these are often patients who have limited income protection due to either being self-employed, on low income, or not being entitled to sick pay arrangements. In these circumstances, many of the GPs and ANPs in this study explained how they often had to encourage patients to take time off work to improve their health and often suggested that a short-term fit note of 1-2 weeks with a reassessment was a helpful approach.
Relieved to be provided with a fit note – these tend to be patients who may have been concerned about their capacity to work or worried about ‘letting down’ colleagues and, therefore, often view the provision of a fit note as legitimising their health concern and its impact on their fitness for work.

Routine patients

These are patients who have had a planned operation in hospital. In these cases, the fit note tends to be secondary to the operation and is usually issued at a later date. There were, nonetheless, some inconsistencies expressed across the interviews with GPs and ANPs in terms of whose responsibility it is to issue fit notes following an operation. Therefore, some fit notes are provided by GPs following an operation whilst others are provided directly after the operation by the hospital doctor.

Emergencies

These are cases when a patient presents with symptoms that require emergency treatment (e.g. appendicitis, broken bones). In these cases, the fit note tends to be entirely secondary to diagnosis and treatment, and is often issued at a later date when the patient’s condition is more stable.

Question 10

5.2  Assessment of the patient

Accepted Answer

Over the course of the study, most of the GPs and ANPs explained how they continually sought to understand the nature of their patient’s health condition and how it may impact on, or be impacted by, their work. Rather than ‘work and health’ conversations being triggered by a patient’s request for or need of a fit note, GPs and ANPs frequently described how the interaction between an individual’s work and health condition formed the basis of healthcare assessments, enabling them to build a holistic picture of their patient. The following provides an overview of the various steps, along with their associated challenges, that many of the GPs and ANPs identified as integral to assessments of a patient’s fitness for work:

Explore the patient’s clinical history → this helped GPs and ANPs to better understand the nature of the patient’s health condition, whether they were also managing any other health conditions, as well as providing an overview of any ongoing treatment plans and medications.
Sensitively explore the reasons for the current appointment → this often involved explaining to patients that in order to provide appropriate care, they may need to ask a range of questions about their health and its impact on their life. This helped to ensure that patients did not feel as though the GP or ANP was prying, and, consequently, helped to overcome some of the barriers to a successful assessment, such as a patient’s embarrassment or defensiveness
Sensitively probe the patient’s employment status and job role → many of the ANPs and GPs explained how it was important to find out about the nature of the patient’s work^{[footnote 20]} and how this related to their health condition or reason for booking an appointment in order to assess their fitness for work. They explained that this often necessitated questioning the patient sensitively and indirectly, i.e. asking “what would you be doing if you weren’t here today?”, so that patients did not feel under pressure to return to work before they were able to.
Explore the conversations, if any, that the patient has had with their employer → many of the ANPs and GPs explained that this element of the assessment was critical as it helped them to decide whether or not to recommend workplace adjustments (the ‘may be fit for work’ option on the fit note). For example, if the patient was suffering from stress or anxiety, and the GP or ANP suspected it may be work-related, they would seek to understand whether the patient had discussed things like their workload or the nature of their responsibilities with their employer. The course of action subsequently taken depended on the individual ANP or GP. Some used the ‘may be fit for work’ option to facilitate discussions between the employee and employer, whilst others asked the employee to discuss this with the employer before any fit note was issued.
Manage patient expectations around their return to work → in some cases, GPs and ANPs described how certain patients were reluctant to be told that they were not fit for any work (namely, the self-employed, those on low income or in insecure work – see discussion in section 5.1 for further details). When they sensed this may be the case, GPs and ANPs explained that it was important to make it very clear to these patients that, in their professional opinion, they currently were not fit for work and that having some time off from work would be beneficial for their health in both the short and long term.

Underlying all of these elements of the assessment process was the need to offer medical advice that was in the best interests of the patient whilst maintaining the patient-clinician relationship with them. GPs and ANPs explained that maintaining a positive relationship with their patient was one of the most important aspects of their medical practice because it built mutual respect and trust. For example, a number of the GPs explained that they expected their patients to comply with treatment plans, but that in return patients expected GPs to offer medical advice that would ultimately result in improved health or a better quality of life following treatment. With both sides expecting the other to respect their time and opinion, GPs and ANPs explained that damaging this relationship had the potential to result in the patient feeling unheard or disrespected and, consequently, in poorer health and wellbeing outcomes.

5.3 Current barriers to effective work and health conversations

One of the biggest challenges that the majority of GPs and ANPs described they confronted during the process of assessing fitness for work was the short consultation time they had with patients. Many of the GPs and ANPs explained that it was difficult with a 10-15-minute appointment to build a holistic picture of the patient which allowed them to adequately assess their capacity to work. As a result, a number of the GPs and ANPs reported that they had to make decisions quickly to the best of their ability, but would often give more brief, non-specific advice than they wanted to because of the time constraints.

I don’t have the power to say to a patient ‘I don’t agree with you, I think you should go to work’, if a patient says I can’t work… As a GP, we only have 10 minutes with the patient, and we’re certainly not trained to assess people’s occupational health.

(General practitioner)

These time constraints often appeared to be compounded by the need for GPs and ANPs to manage the varying needs and expectations of their patients. For example, some GPs and ANPs described how they often had to spend considerable time advising patients about the impact of their health on their capacity to work. This appeared to be particularly the case for individuals in low-paid and insecure work and for those individuals worried about the perception of their employer or colleagues to any periods of sickness. Many GPs and ANPs highlighted the delicate balance, in these cases, between assessing an individual’s fitness for work and awareness that any period of sickness absence from work could lead to considerable financial difficulties and further deteriorations in their patient’s health and wellbeing.

The risks arising from these tensions led some of the GPs and ANPs to describe how some ‘requester’ patients (see section 5.1) could become aggressive during the consultation if they did not agree with the assessment of their fitness for work. In these cases, patients often appeared to feel as though the severity and authenticity of their health condition was being questioned.

Fit notes can be a major source of conflict between a doctor and a patient. I’ve had instances where patients have become aggressive, and even violent, and I’ve issued a fit note just to de-escalate the situation, and get the patient out of my consultation room. I’ve had situations where issuing a fit note was the only safe way out. I’ve even had to call the police before.

(General practitioner)

As a result, some of the GPs and ANPs explained how in these types of circumstances they often sought to manage the situation by issuing short-term fit notes and requesting the patient return for a re-assessment. This provided GPs and ANPs with more time to discuss and explain their assessments of fitness for work and also acted to diffuse immediate confrontational situations.

Consequently, in this study, the majority of GPs and ANPs were relatively reluctant to refuse to issue a fit note unless it was clear that it was inappropriate and did not support the patient’s health in the short or longer term. Refusing to issue fit notes was often noted to lead to confrontation, which could jeopardise and undermine the doctor-patient relationship. GPs and ANPs often explained that it was particularly difficult to refuse fit notes when another GP in their practice had extended sickness absences without any further reassessments. In these circumstances, many of the GPs and ANPs spoke of the challenges to having in-depth work and health conversations and how, in many instances, this led to fit notes being further extended.

Sometimes if they’ve been to see another member of staff in the practice first, sometimes they’ll come in with an expectation of, you know - doctor so and so gave me a note before and now you’re asking me all these questions. That makes it a bit difficult sometimes, you feel we’re not perhaps all singing from the same hymn sheet.

(Advanced nurse practitioner)

Critically, for this study, a number of ANPs reported that, in some cases, when fitness for work assessments became challenging, they would refer the patient to their GP for reassessment. This action appears to safeguard the relationship between the ANP and patient by providing a secondary clinical opinion but may also explain why some of the patients in this research questioned the suitability of ANPs to adequately assess fitness for work and believed that GPs are, on the whole, better placed to issue fit notes.

Question 11

6.  Views on the ‘may be fit for work’ option

Accepted Answer

This chapter explores the attitudes and experiences of HCPs, employers and patients towards ‘may be fit for work’ fit notes. These discussions examine the perceived benefits of fit notes that provide workplace advice, the current barriers to greater use of this fit note option, and also identify potential approaches that may encourage more HCPs to assess an individual as ‘may be fit for work’ depending on workplace adjustments in the future.

On the whole, all of the participant groups viewed the ‘may be fit for work’ option as a way to support individuals to remain in or return to employment. There was, however, a clear need expressed by all of the participant groups for further information and guidance about how to both provide and action the workplace adjustments provided by HCPs on these types of fit notes so that they reflected both the needs of the individual in poor health and their employer. The key messages from each group are discussed in turn below.

6.1 HCP experiences of ‘may be fit for work’ fit notes

The vast majority of GPs and ANPs described how having the capacity to advise returns to work with reduced hours or amended duties offered considerable benefits to the health and wellbeing of their patients. A number of GPs and ANPs, for instance, noted the importance of the ‘may be fit for work’ option as it offered them the opportunity to focus on a patient’s capabilities and capacity rather than the limitations of their health condition. Furthermore, most GPs and ANPs viewed phased returns as a key factor to successfully supporting patients to transition back into the workplace. Such approaches provided patients with an opportunity to gradually build up their stamina and strength, which would eventually support a return to their usual working routines. Importantly, many of the GPs and ANPs indicated that a gradual transition to full-time hours appeared to enable their patient to remain in work once they returned to their usual working hours, and to be less likely to need further time off work due to ill-health in the future.

In particular, phased returns were frequently cited by GPs and ANPs as being particularly important for patients with mental health conditions as these individuals often tended to benefit from the routine and structure that work provided and may be at risk of having lengthy periods of sickness absences from work without any workplace adjustments.

It’s fantastic, and should be used more. If you’re at work, but doing lighter duties, you’re getting the benefits of getting up, routine, earning money… You’re maintaining your quality of life, and positivity, and still contributing to the workplace.

(Advanced nurse practitioner)

More generally GPs and ANPs believed that advising patients that they had the capacity to assume work with workplace adjustments served to empower patients. The ‘may be fit for work’ option was thought to support patients to confidently initiate conversations with their employers about what they could and could not do in the workplace, with the backing and authority of a medical professional. As a result, some of the GPs and ANPs said that they sometimes kept the level of detail on the fit notes deliberately vague, in order to empower the patient to have these conversations with their employer. If workplace adjustments were too specific, these GPs and ANPs sometimes worried that employers would feel justified in giving their employee tasks or roles that they may not always be comfortable doing given their health condition. In these circumstances, a fit note which provided detailed workplace advice was therefore seen to potentially compromise the employee’s capacity to refuse to undertake these tasks.

Interestingly, GPs and ANPs often explained how they found assessing fitness for work to be easier when patients had already discussed potential workplace adjustments with their employer. Many, for example, commented on how they could more easily recommend suitable workplace adjustments when they had a clear sense of the type of workplace advice that was able to be implemented by the employer. This led assessments to often be more productive as GPs and ANPs tended to have a clearer sense of the types of workplace recommendations that employers may be able to implement.

I think employers should be a little bit more flexible. I have quite a few people who are willing to go back to work on light duties or amended duties, and are unable to because their work are not supportive of that - it’s all or nothing for them.

(Advanced nurse practitioner)

Many of the GPs and ANPs, however, suggested that employers appeared to be often resistant to implementing workplace adjustments recommended on fit notes. It was noted that this did not mean that employers were being deliberately obstructive but rather seemed to lack real understanding of the benefits to both the patient and themselves of implementing workplace adjustments. In particular, a number of the GPs and ANPs believed that some employers had preconceived ideas and concerns about providing employees with phased returns, lighter duties, or reduced hours, and frequently did not want to bear the risk of having someone who was not ‘fully fit’, i.e. able to do 100% of their role, return to work. As a result, some of the GPs and ANPs described how they did not have the specialist training to be able to recommend appropriate workplace adjustments which employers could implement and explained that, in many cases, occupational health specialists tend to be better placed to give tailored workplace advice.

6.2 Patient experiences of ‘may be fit for work’ fit notes

The majority of those participants who had been assessed as ‘may be fit for work’ described positive experiences of receiving their fit note and its associated recommended adjustments.^{[footnote 21]} Many patients often explained how their workplace adjustments, such as phased returns to work, had enabled them to return to their job after a period of sickness absence and, therefore, helped to support their longer-term recovery. Remaining in work, at least in some capacity, was frequently noted to help support patients’ mental health as it provided a sense of routine and enabled continued socialisation with work colleagues.

The discussion I had with my consultant once the cast [on my leg] came off was more on my terms, as we were able to think about returning to work. We agreed it would be good to start on no more than five hours at a time, and over two days a week rather than my usual three. He said it would be important to tell my employer I could sit down and take breaks when I needed. I had that fit note for two weeks, then we reviewed where I was and he gave another for six weeks. My employer agreed to everything in the fit note and it all worked really well as far as I was concerned. I actually ended up going back to work on normal hours two weeks earlier than planned, but felt that if I needed more time I could’ve asked.

(Patient, physical health condition, mostly manual work)

When workplace recommendations had been general, some patients described having greater control over the ways in which adjustments were implemented by their employer. In the majority of cases, however, patients explained that vague workplace adjustments had seemed to result in a level of confusion, leaving their employer uncertain about how to implement such broad and general advice. A number of the patients in this study, therefore, noted that their employers may have benefited from workplace adjustments that had been more explicit and detailed.

I guess having a bit more information on what I could do and things my employer could help me would have been more helpful to them [employer] and it would have given me more confidence to say yes I can do this task but I might need breaks or I need a new chair with arm rests to support my arm etc.

(Patient, physical condition, mostly office-based)

In contrast, when GPs and patients had agreed on clear and actionable adjustments, such as a variation in working hours, patients often reported positive experiences of their employer taking those on board with almost no negotiation. In many cases, fit notes with recommended workplace adjustments had been issued for a short period of time (i.e. 2 weeks) in order to review how modifications to workplace practice were working in practice and to allow for any necessary changes. Following this, many patients were aware that they could return to their GP if they felt that any workplace adjustment had become unsuitable but most described that they had not done so because they worked closely with their employers through regular reviews or informal meetings. This reciprocal approach tended to be generally welcomed by many of the patients because it was often believed to provide an effective approach that enabled them to remain in their job.

However, some of the patients described frustration with their employer because they had to continually remind them about their agreed workplace adjustments. Often these patients explained that their employer had appeared supportive at the outset when arranging and implementing workplace adjustments but later had appear to disengage and forget about their continued need for modifications to their work duties. The need to remind their employer of the ways they needed to be supported to remain in employment was frequently described as a stressful experience that often impacted on their health.

6.3 Employer experiences of ‘may be fit for work’ fit notes

In principle, the vast majority of the employers interviewed could see the benefits of fit notes providing workplace adjustments. Phased returns to work were particularly noted by employers to be beneficial as it both provided employees with a gentler introduction to full-time work and duties whilst enabling the organisation to continue to retain the skills, experience and productivity of their employee.

We’d always rather the person was able to make a contribution, because that contribution is valuable, in terms of the knowledge and experience that person has. If they’re able to contribute, even for a fewer number of days a week, then that is still a contribution that’s worth having.

(Employer without experience of fit notes, 2-9 employees, no HR function, mostly office-based work)

However, the majority of employers described how it was sometimes difficult to act on fit notes because the information was not always clear, unambiguous or written in plain English. Many spoke about how they needed fit notes to provide an explanation of any clinical or medical diagnosis in order to fully understand their employee’s health condition and tailor workplace support appropriately. In addition, a number of employers noted the importance of fit notes including more details about any further tests and treatments that their employee may require. They explained that having this information could potentially help them to understand the severity of their employee’s health condition and also offer reassurance that they were receiving appropriate support.

I’d like fit notes to have more detail about the condition and whether the person is getting treatment. Somebody that’s just got ‘stress’ written on the comments of a fit note, well that doesn’t give you much scope as to where you go from there. If it was ‘stress and attending a clinic’ or some sort of counselling, you might then think there’s something being done in the background to assist with that condition.

(Employer with experience of fit notes, 50-249 employees, HR function, mix of manual and office-based work)

Some employers also echoed the experiences of patients and described how they often required further and more detailed information about how to implement the workplace adjustments recommended by HCPs. Having greater detail about the potential impact of an employee’s health on their fitness to work and the timeframe for their recovery was often noted by employers to lead to increased confidence that their actions would support their employees to return to and remain in work and enable them to plan at an organisational level. This appeared to be particularly the case for fit notes issued for workplace stress, as many employers often spoke about how they wanted more information on how and why the working environment was causing stress and how they could best work with their employee to overcome these issues.

Detailed information about workplace adjustments also seemed to be particularly critical for those employers operating in manual or hazardous environments where the nature of the work posed heightened health and safety risks. These employers explained how they were sometimes unwilling to bear what they perceived as the additional risk of having an employee return to work before they were ‘fully fit’ to fulfil their role. As a result, a number of the employers reported how they would prefer only to have an employee return when they had been certified as fit for all of their role as this meant there was likely to be less risk that their health may be compromised at work.

Importantly, in some cases, this need for further information had led a number of employers to report that they had, with the consent of their employee, contacted the GP who had issued the fit note to gain a better understanding of the nature of the employee’s health condition and how they could best support them at work. However, the level of detail frequently required by employers often appeared to exceed the general fitness for work advice a GP is able to offer and to transition into the domain of OH professionals.

It’s quite frustrating the level of detail some of the doctors will put on fit notes… We’ve had fit notes before where it just says ‘unwell’ and you’re like ‘well what does that mean?’ and they’ve been signed off for a month… ‘Does that mean they’ve got a cold? They’ve broken their leg?’. Unless your employee’s going to then give you more information… you can’t do anything [to support them] as you don’t know what the issue is. That’s really not uncommon…’

(Employer with experience of fit notes, 50-249 employees, HR function, mostly office-based work)

This need by employers to have a greater understanding of an employee’s fitness for work and to be provided with detailed workplace adjustments specific to the job role of the employee emerged as a key finding in this research study. It highlights potential discord between the level of detail that many employers would like from fit notes to support their employees to return to or remain in work and the type of detail that many HCPs believe they are able to offer due to limited time in consultations and constrained understanding of the roles and responsibilities attached to various jobs. This finding appears to suggest that the extension of certification powers may not necessarily resolve the tensions between the needs of employers and the capacity of HCPs to provide tailored workplace advice. Consequently, alongside extending fit note certification to a wider range of HCPs, it appears important that employers are accessing specialist OH services who are better placed to translate the workplace adjustments provided on fit notes into the specific job role of the individual employee.

Question 12

7.  Returning to work

Accepted Answer

This chapter explores what happens when employees returned to work following sickness absence, including any conversations they had with their GP, other HCP or employer.

7.1 Experience of returns to work

Across the study, there was mixed evidence of patients having been supported to return to work by their employer following a period of sickness absence. When patients spoke positively about their experiences of returning to work, this appeared to be the result of timely and ongoing contact between the patient and their employer during the sickness absence period. Having open conversations about the types of support required by the patient on their return to work and the extent to which this was possible within the organisation appeared to help both parties to construct an effective ‘return to work’ plan.

Figure 7.1: Level of employer-employee contact during periods of sickness absence

Conversations tend to be minimal when…

Sickness absences are ‘short-term’ (i.e. 1-2 weeks)
In these cases, both parties tend to expect the employee would return to work when their fit note ended and that they would require no workplace adjustments
Often employers and employees tend to not to be aware of who is responsible for instigating ‘return to work’ conversations, how often these should happen nor issues to discuss

Conversations tend to be more extensive when…

Sickness absences are longer-term (i.e. over 1 month)
In these cases, larger organisations tend to have ‘return to work’ conversations through formalised sickness absence processes in place (i.e. HR personnel and sickness absence policies)
Alternatively, smaller organisations tend to rely on their tight-knit ‘family’ culture to support their employees by asking for updates on fitness for work through more informal conversations

Similarly, employees who described negative experiences of returning to work often described the importance of ongoing contact with their employer. Many explained how poor communication with their employers during their period of sickness absence meant they were unable to cultivate a shared understanding of the impact of their health condition at work and the subsequent support they required to return to work.

There wasn’t much contact during the first six weeks, and I would’ve expected them to check up on me, how my leg was healing. I was getting x-rays every two weeks, so could’ve updated them if they had asked about my recovery. The lack of contact made me feel annoyed.

(Patient, physical health condition, mostly manual work)

Importantly, this finding was echoed by a number of the employers who explained that they were often unclear about how much contact they should have with their employees during a period of ill-health, whether they should be the ones to instigate this contact, and if there were any legal requirements they should adhere to when an employee returns to employment following sickness absence. This lack of clarity meant that many employers admitted that they struggled to know how to strike the balance between providing their employees with sufficient support to expedite their return to work, while not inadvertently applying pressure that results in them returning too soon.

If somebody’s got a fit note saying they are not fit to work for a certain amount of time, then I don’t think it’s fair to say ‘you’ve got to ring up every two days’ because what’s the point… you don’t want to feel like you’re harassing someone.

(Employer with experience of fit notes, 50-249 employees, HR function, mostly manual work)

In other cases, employers spoke about how they did not have the right to contact their employees at all during periods of sickness absence. This overarching desire to respect the privacy of employees during periods of sickness absence whilst continuing to ensure that employees felt valued was often noted by employers to be a considerable challenge and often compounded by the employer’s need to know when their employee may be able to return to work so that appropriate cover could be planned. A small number of employers also spoke about how they had sometimes been sceptical of an employee’s need for a period of sickness absence. In these instances, the employer’s doubts often seemed to have been compounded by a lack of communication with the employee so they did not have a full understanding of their health condition and its implications on their fitness to work.

Uncertainties about how best to approach and effectively manage contact during periods of sickness absence, consequently, often resulted in both parties feeling less than satisfied with the process. As a result, many of the employers and employees involved in this study spoke about how they would benefit from having further guidance on how to initiate and have ongoing supportive work and health conversations that would help the development of return to work plans.

7.2 Employer experiences of sickness absences without fit notes

Employers who had not experienced fit notes were generally aware of the purpose of the fit note, and explained that their staff had not needed to take enough time off work to merit obtaining medical proof for the sickness absence. These organisations tended to be small, and tightly-knit, with a much more informal approach to supporting employees returning to work. In many cases, these employers described how they had personal as well as professional relationships with their employees. This meant that contact during periods of sickness absences tended to focus mainly on the extent to which the organisation needed to cover the employee’s work for a period of time, the support required by the employee to return to or remain in work, as well as more friendly general enquiries about the individual’s health. These informal conversations, often conducted in the form of a text or phone call, were seen as a replacement to the development of more formal return to work plans.

Generally speaking, in this sort of size organisation, you would tend to rely on a personal relationship. I can imagine in a small organisation [that] it’s always going to be done on a much more informal basis.

(Employer without experience of fit notes, 2-9 employees, no HR function, mostly manual work)

Smaller employers also tended to explain how their work environment and culture helped their employees to share their specific support requirements and that the personal relationship fosters meant that they would try their very best to accommodate these adjustments or find a suitable alternative. Clear communication and frequent contact between the employer and their employee, therefore, also appeared to be important element of more informal return to work processes.

Question 13

8.  Summary and Recommendations

Accepted Answer

Extending fit note certification powers beyond GPs to a wider range of appropriate healthcare professionals was well received and endorsed by all participants involved in the research.

The extension of fit note certification powers was seen as a valuable policy change with a number of potential benefits, including:

Enabling more detailed and tailored workplace advice to be provided to both patients and their employers.
Reducing current time and workload pressures on GPs.
Minimising duplications in effort and resources in the current fit note process.
Ensuring more effective use of healthcare professional time and NHS resources.
Providing a better ‘fit note experience’ for patients, employers and healthcare professionals.

However, a number of challenges to the successful delivery and implementation of the extension have been identified. These include concerns that:

Some HCPs may not be as professionally qualified and regulated as GPs and hospital doctors to assess fitness for work and issue fit notes.
HCPs may be able to issue fit notes for health conditions outside of their scope of clinical practice.
Poor accessibility to patient clinical records may lead to duplicate fit notes being issued.
Extension of fit note certification powers is unlikely to resolve the current discrepancy between the level of detail that employers expect from a fit note and the type of workplace advice that HCPs are able and required to provide within fit notes; although widening certification to include HCPs, such as physiotherapists and occupational therapists, may potentially improve the return to work advice provided.

There was a strong sense across the participant groups that the potential benefits of the fit note extension would outweigh these risks. In many cases, it was felt that these risks could be effectively mitigated.

8.3 Recommendations for fit note delivery and policy implementation

A number of recommendations have emerged from this research study which have the potential to enhance the current fit note process and support the effective implementation of extension to fit note certification powers in the future.

8.3.1 General delivery recommendations

Ensure all HCPs who can certify fit notes in the future operate at an advanced level, are registered and licensed to practise clinically, have received relevant training on how to assess fitness for work and complete and issue fit notes, and have access to ongoing mentoring at a local level.
Ensure all HCPs qualified to issue fit notes can access electronic fit notes, have an appropriate level of access to patient clinical records and consider phasing out handwritten paper fit notes.
Consider key sections of fit notes, such as the section on the functional effects of health conditions, becoming mandatory to support consistency between different HCPs and ensure enhanced levels of detail to be provided on the fit note.
Consider providing ‘good practice’ guidance with updated case study examples to help HCPs assess fitness for work, and support employers and employees better manage sickness absences and returns to work.
Raise awareness of current fit note guidance documents available to HCPs, patients and employers.
Consider options to embed ‘good practice’, potentially by encouraging ongoing supervisions or mentoring at a local level.

8.3.2 Communication and policy implementation recommendations

Raise awareness amongst HCPs, employers and patients of the following:
- Fit note certification extension and its implications for HCPs, employers and patients.
- The length and purpose of the 7-day self-certification period.
- The capacity for HCPs to assess individuals as ‘may be fit for work’ with workplace adjustments.
- Potential benefits of remaining in, or returning to good quality work for both individuals with health conditions and their employer.
- The relationship between the role and remit of the fit note, the NHS and wider occupational health services accessed through employers.
Pilot the rollout of the fit note certification extension and develop feedback mechanisms to improve ongoing delivery and implementation.
Establish an approach which identifies any benefits and challenges arising from implementation of the fit note extension.

8.4 Further considerations

This research has also identified a number of areas requiring further research. These include the need for further consideration of:

The ways in which fit note certification extension may impact on individuals with complex health conditions.
The ways in which the information provided within fit notes currently interact with, and support, occupational health services provided by many employers.

Question 14

9.  Appendix

Accepted Answer

9.1 Sampling and recruitment

Employers were mainly recruited from those who had agreed to be re-contacted during the ‘Sickness absence and health in the workplace: Understanding employer behaviour and practice’ survey, conducted by Ipsos MORI during the summer of 2018. Employer sample was supplemented via free-find recruitment. Patients were recruited via free-find methods, and HCPs were recruited through a mix of commercially available sample (Wilmington Healthcare) and free-find recruitment.

Table 9.1: Sampling matrix (achieved v. quota)

Audience	Target	Achieved
GPs	10	10
ANPs	10	10
Other HCPs	10	10
Employers who have experienced fit notes	16	17
Employers who have not experienced fit notes	7	6
Patients	15	15
Total	68	68

GPs – 10 interviews

Characteristics	Description	Quota	Achieved
Status	Partner	Mix/Monitor	3
	Salaried		7
Urban/rural	Rural		3
	Urban		7
Location	East Midlands		-
	East of England		1
	London		3
	North-East		1
	North-West		1
	Scotland		-
	South-East (excluding London)		2
	South-West		-
	Wales		-
	West Midlands		1
	Yorkshire & Humberside		1

ANPs – 10 interviews

Characteristics	Description	Quota	Achieved
Urbanity	Rural	Mix/Monitor	7
	Urban		2
	Suburban		1
Location	East Midlands		1
	East of England		1
	London		-
	North-East		-
	North-West		-
	Scotland		1
	South-East (excluding London)		3
	South-West		-
	Wales		-
	West Midlands		2
	Yorkshire & Humberside		2

Other HCPs – 10 interviews

Characteristics	Description	Quota	Achieved
Profession	Specialist nurses (OH nurses)	Min. 2	2
	Physiotherapists	Min. 2	2
	Occupational therapists	Min. 2	2
	Pharmacists	Min. 2	2
	Mental health professionals	Min. 2	2
Urbanity	Rural	Mix/Monitor	-
	Urban		10
Location	East Midlands		1
	East of England		-
	London		3
	North-East		1
	North-West		-
	Scotland		-
	South-East (excluding London)		3
	South-West		-
	Wales		-
	West Midlands		2
	Yorkshire & Humberside		-

Employers with experience of fit notes (17 interviews)

Characteristics	Description	Quota	Achieved
Work environment	Manual environment	Min. 4	5
	Office-based environment	Min. 4	5
	Mixture	Min. 4	7
HR type	Internal HR department (or HR consultants)	Min. 4	13
	No internal HR resource	Min. 4	4
Occupational Health type	OH-user (contract in place)	Min. 4	5
	Non-user (no contract in place)	Min. 4	12
Fit note uses	Fit note for mostly physical conditions	Mix/Monitor	10
	Fit note for mostly mental ill-health		1
	Fit note for both physical and mental ill-health		6
Recommended adjustments	Fit note recommended adjustments	Mix/Monitor	13
	Fit note did not recommend adjustments		4
Size (number of employees)	2-9	Mix/Monitor	5
	10-49		3
	50-249		7
	250+		2
Sector	Agriculture and Energy	Mix/Monitor	-
	Manufacturing		1
	Construction		1
	Distribution, Hotels and Restaurants		4
	Transportation and Communications		3
	Banking and finance		4
	Public Administration, Education and Health		1
	Other services		3
Location (GB)	East Midlands	Mix/Monitor	-
	East of England		2
	London		1
	North-East
	North-West		1
	Scotland		1
	South-East (excluding London)		2
	South-West		4
	Wales		2
	West Midlands		3
	Yorkshire & Humberside		-
	Northern Ireland		1

Employers without experience of fit notes (6 interviews)

Characteristics	Description	Quota	Achieved
Work environment	Manual environment	Min. 2	3
	Office-based environment	Min. 2	3
HR type	Internal HR department (or HR consultants)	Min. 2	2
	No internal HR resource	Min. 2	4
Occupational Health type	OH-user (contract in place)	Min. 2	1
	Non-user (no contract in place)	Min. 2	5
Size (number of employees)	2-9	Mix/Monitor	4
	10-49		2
	50-249		-
	250+		-
Sector	Agriculture and Energy	Mix/Monitor	-
	Manufacturing		-
	Construction		3
	Distribution, Hotels and Restaurants		1
	Transportation and Communications		-
	Banking and finance		1
	Public Administration, Education and Health		-
	Other services		1
Location (GB)	East Midlands	Mix/Monitor	1
	East of England		1
	London		1
	North-East		-
	North-West		1
	Scotland		2
	South-East (excluding London)		-
	South-West		-
	Wales		-
	West Midlands		-
	Yorkshire & Humberside		-
	Northern Ireland		-

Patients (15 interviews)

Characteristics	Description	Quota	Achieved
Age	18-34	Mix/monitor	7
	35-54		7
	55+		1
Reason for fit note	Mental ill-health	Min. 4	5
	Physical ill-health	Min. 4	9
	Both	None	1
Adjustments recommended	Fit note recommended adjustments	Mix/monitor	10
	Fit note did not recommend adjustments		5
Sector	Agriculture and energy	Mix/monitor	1
	Manufacturing		-
	Construction		-
	Distribution, hotels and restaurants		3
	Transport and communications		1
	Banking and finance		5
	Public admin, education and health		2
	Other services		3
Socioeconomic background	ABC1 ^{[footnote 22]}	Mix/monitor	10
	C2DE ^{[footnote 22]}		5
Work type	Manual	Min. 4	5
	Office Based	Min. 4	8
	Mix	None	2
Location	East Midlands	Mix/monitor	1
	East of England		3
	London		1
	North-East		-
	North-West		5
	Scotland		-
	South-East (excluding London)		3
	South-West		2
	Wales		-
	West Midlands		-
	Yorkshire & Humberside		-
	Northern Ireland		-

Please note that the sector combinations above were defined as follows:

Sector	Definition
Agriculture and Energy	Includes: Agriculture, Forestry and Fishing; Mining and Quarrying; and Utilities, Waste Management and Remediation Activities.
Banking and Finance	Includes: Financial and Insurance Activities; Real Estate Activities; Professional, Scientific and Technical Activities; and Administrative and Support Service Activities.
Distribution, Hotels and Restaurants	Includes: Wholesale and Retail Trade; Repair of Motor Vehicles and Motorcycles; and Accommodation and Food Service Activities.
Other Services	Includes: Arts, Entertainment and Recreation; and Other Service Activities.
Public Administration, Education and Health	Includes: Public Administration, Defence and Compulsory Social Security; Education; and Human Health and Social Work Activities.
Transport and Communications	Includes: Transportation and Storage; and Information and Communications.

Question 15

Topic guides

Accepted Answer

Slightly different topic guides were used depending on the audience, though the core questions were similar. Below, we have included the topic guide for employers with experience of fit notes.

Topic guide: Employers with experience of fit notes

1. Introduction

2-3 minutes

Orientates interviewee, prepares them to take part in the interview.

Outlines the ‘rules’ of the interview (including those we are required to tell them about under MRS and GDPR guidelines).

Thank participant for taking part. Introduce self, and explain nature of interview: informal conversation; gather all opinions; all opinions valid. Interviews should take around 45 minutes.
Introduce research and topic – the Work and Health Unit (a joint unit between the Department for Work and Pensions and Department for Health and Social Care) has commissioned Ipsos MORI to conduct research with employers to understand their views on extending who can issue fit notes. Employers have been asked to take part in this interview because they took part in a survey on a similar topic over the summer.
Role of Ipsos MORI – Independent research organisation (i.e. independent of government), we adhere to the MRS Code of Conduct.
Confidentiality – reassure all responses anonymous and that identifiable information about them will not be passed on to anyone, including back to WHU or any other government department.
Consent – check that they are happy to take part in the interview and understand their participation is voluntary (they can withdraw at any time).
Ask for permission to digitally record – transcribe for quotes, not detailed attribution. Only non-identifiable information will be passed back to WHU.
Any questions before we begin?

2. Context

5 minutes

Provides contextual background information about the participant and their organisation.

To start, I’ll ask a few broad questions about your role and the nature of your organisation.

Can you tell me a bit about what the organisation you work for does?

Sector
Size
Length of time in operation
Briefly explore the nature of the work and range within the business (e.g. manual, office based, mixed)

And can you talk me through what your role involves?

Specific HR role / senior management / owner or director / Wellbeing professional/ line manager
Explore their responsibilities/experience/qualifications in relation to employee health and wellbeing
Length of time in this role
What is the most common reason why employees tend to be ill and off work? E.g. physical or mental health?
Generally, are most of your employees off work for a short or long period of time if they have poor health?

3. Attitudes towards health, wellbeing and work

5 minutes

Explores their attitudes towards health and wellbeing, specifically the role of work within this

Before we talk about fit notes, it would be useful to explore your thoughts on what affects employees’ health and wellbeing.

In your experience, how can work affect employees’ health and wellbeing?

Explore how work has a positive impact
Explore how work has a negative impact
If it has no effect – why?
Evidence – research, from patients, opinion, anecdotal evidence
Briefly explore work’s impact relative to other factors

In your opinion, whose role is it to support the health and wellbeing of employees?

Probe on relative importance of: patient, employer, HCP, government

4. Employers’ approaches to employee health and wellbeing

10 minutes

Explores whether employers support their employees in health and wellbeing terms, and why/why not.

I’d now like to move on and talk about the ways you, as an employer, support your employee’s health and wellbeing.

Can you tell me a bit about any challenges that tend to arise for your business when an employee becomes unwell?

E.g. decreased productivity, having to shift workload to colleagues etc.
Would you at any time advise that an employee take sickness leave?
- When? Why?
- What implications does this have for your business?

What kinds of things, if any, does your organisation currently do to support the health and wellbeing of your employees?

Probe:
- Health and safety training or guidance
- Health and wellbeing programmes (e.g. health food choices, health advice, health and wellbeing information on the intranet, loans or discounts on bicycles or gym membership)
- Interventions to prevent common health conditions becoming a problem (free health checks, vaccinations, smoking or weight-loss support)
- Training for line managers on ways to improve employee health and wellbeing
- Employee Assistance Programme or staff welfare/counselling programme
- Flexible working (working from home, term-time working, compressed hours, time off in lieu)
- Other staff perks: More than 20 days annual leave, employer contribution to employee pensions, enhanced maternity or paternity pay
- Occupational health service
Are these resources/services available to all employees? If an employee was on sickness leave, do they continue to be eligible to these resources? Why/why not?

Why do you provide / not provide these things to support the health and wellbeing of your employees?

Probe why they provide:
- Sense of duty/moral obligation
- Prevent ill-health/costs of sickness absence
- Reward loyalty/show employees we care
- Cost-benefit analysis
- Legal obligation
- Meet employees’ expectations
Probe why they do not provide:
- Lack of time
- Lack of expertise/information
- Lack of resources
- Attitudinal barriers (i.e. don’t think it is employer’s role, don’t believe investing in health and wellbeing is worth it)

To what extent do you feel these measures support your employees to maintain or improve their health at work?

Why/why not?
Is there anything else you believe would support your employees? Why?
- What is preventing you from providing these? E.g. not enough resources, time-limited, only can provide to employees with physical health issues etc.

Are there any circumstances where you feel unable to support an employee in poor health?

E.g. if it depends on the employee/their employer/the illness/other circumstances, then what do these look like?
Probe: lack of knowledge/specialist expertise, employee doesn’t want support, don’t feel it’s employers’ remit
Probe: for examples of this

How confident do you feel about knowing how to improve employees’ health and wellbeing at work?

What would help you to become more confident?
Where do you seek advice from? Whose responsibility is it to act on advice?
Are there any barriers or constraints that impact on your capacity to support employees whose health is impacting on their capacity to work? E.g. not enough resources, time, no official processes in place etc.

5. The current fit note process

10 minutes

Overview of how the fit note works in relation to their organisation, and how well or not well this is working.

I’d now like to explore your experiences and views of the fit note as an employer.

In your own words, can you describe to me what you think the purpose of the fit note is?

Explore awareness of change from sick note to fit note

Generally speaking, at what point does the organisation become aware that an employee’s health is impacting on their capacity to work?

What steps do you take when you become aware that an employee’s health is impacting on their capacity to work?
What conversations do you tend to have with employees who become unwell?
- What makes these conversations easier/more difficult?
At what point do you request a fit note from your employees? Why?

What steps do you take when you receive a fit note from an employee?

Who is responsible for receiving fit notes in your organisation? (HR, senior management, line manager, owner, other)
When you receive the fit note, what conversations do you have at this point?
- How do you prepare for these conversations?
- Who is involved? (HR, line manager, OH professional)
- How involved is the employee?
- How are decisions made?
Whose responsibility is it to act on any advice given in the fit note?
How do you use fit notes within your organisation? (e.g. to instigate sickness absence procedures, provide medical verification)
Do you have any interaction with the person issuing the fit note? If so, how? (probe on whether communication is only done indirectly, through the patient)

What do you expect from your employee during the time they have a fit note?

How regularly do you have contact?
How is the employee’s progress reviewed?
Who is involved in determining whether employees are fit to return to work? (e.g. employee, employer, GP)

When do you feel employees should return to paid work?

Probe: if it depends on the employee/the illness/other circumstances, then what do these look like?
Probe: for examples to illustrate the factors involved in the decision
Probe: when they can do some of their work, most of their work, or all of their work

How do you handle an employees’ return to work?

Do you develop a return to work plan?
- Who is involved in this? (employee, HR, line manager, GP, OH)
- How involved is the employee, in particular?
What happens if an employee is unable to work for an extended period of time?
- Probe for an example of this

What information was contained in the fit note/s you received?

Probe: information about employee health condition, impact on capacity to work, advice and guidance to support the employee at work
How helpful did you find the fit note?
Does the fit note provide all the information you need?
What other information would you need from the fit note? Why would this be useful?
- Specific timings
- Adjustment details
- More help for employee/employer
- More detail on next steps
- Signposting to advice/guidance
- More detail on employee condition
- Anything else?

Sometimes fit notes can be issued with the ‘may be fit for work’ option, which means employees can return to work but with reduced roles or responsibilities. What is your experience of the ‘may be fit for work’ option so far?

How was this fit note used?
Can you provide examples of where this has been used?
How involved were you/the employee?
How was the employee’s progress reviewed?
How were the workplace adjustments monitored?
Have you ever found it difficult to accommodate a recommendation / could you think of examples where you would find this difficult, why?
In your opinion, do you think this option should be used more? Why/why not?
If no experience: do they think this information would be useful?
- What are the benefits of these recommendations?
- What are the challenges?

Overall, what are your views on how well, or not, the fit note process currently works?

What works particularly well? What should they continue doing? Why?
What could be improved? How? Why?

6. Extending the certification of fit notes

10 minutes

Explores attitudes towards other HCPs issuing fit notes, how they think employers/colleagues will react to this, and any concerns they might have.

As you know, we are interested in different audiences’ views on extending fit note certification powers to other HCPs, beyond GPs.

Currently, only doctors can issue fit notes to employees. What skills do you think GPs need to be able to assess whether an employee is fit for work?

In your experience, do you think GPs have always understood the impact of your employees’ health conditions on their work? Why/why not?

Do you think other HCPs might have been better placed?

Which ones?
Why?

Are there any HCPs you think would not be well placed to assess fitness for work?

Why/why not?
What impact would it have if you received a fit note from one of these HCPs?
Explore briefly their thoughts on the following HCPs, if a prompt is needed:
- Advanced Nurse Practitioners (ANPs are highly experienced and educated nurses who are able to assess, investigate, diagnose, and prescribe)
- Specialist Nurses in occupational health
- Physiotherapists
- Occupational Therapists
- Pharmacists
- Mental Health professional

What difference, if any, would it make if an employee had a fit note for an extended period of time?

Would one of these HCPs be better placed to issue it than the others? Why/why not?
Would you expect their fitness for work to be assessed by a doctor? Why/why not?

Do you have any concerns about extending who can issue the fit note?

Why?
What would help to alleviate those concerns? Why?
- Campaigns/advertising/marketing
- Information packs
- Training/seminar/webinar sessions

What do you think the benefits might be of extending who can issue fit notes?

7. Summing up

2-3 minutes

We are coming to the end of the interview, but I have a few final questions before we finish.

Brings the conversation to a close, and allows participants time to mention anything that has not already been covered.

Thinking about everything we’ve discussed today, what is the most important message to pass back to the WHU about extending fit note certification?
Is there anything else you would like to mention that we haven’t had the opportunity to discuss?

Thank participant for their time and reiterate confidentiality. As discussed on the phone with our recruiter, we will be providing them with a £50 charitable donation from Ipsos MORI, as a thank you for their time and contribution to the research.

Explain next steps for the research and close – report will be published in summer 2019

The Kings Fund (2010), Managing Acute Illness, available at: https://www.kingsfund.org.uk/sites/default/files/field/field_document/managing-acute-illness-gp-inquiry-research-paper-mar11.pdf Accessed 20.8.19 ↩
Royal College of Nursing (2018) Advanced Practice Standards, available at: https://www.rcn.org.uk/professional-development/advanced-practice-standards Accessed 12.8.19 ↩
Please see: https://www.england.nhs.uk/ahp/about/ ↩
For more information, including definitions, please see: https://www.england.nhs.uk/ahp/role/ ↩
The Kings Fund (2019) Long-term conditions and multi-morbidity, available at: https://www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-long-term-conditions-multi-morbidity Accessed 12.8.19 ↩
DWP, Sickness absence and health in the workplace: Understanding employer behaviour and practice, 2019, ↩
For more information, see: https://www.gov.uk/statutory-sick-pay ↩
For more information, please see: https://www.gov.uk/government/groups/work-and-health-unit ↩
Please note that individuals who had received a fit note whilst out-of-work were not recruited to be involved in this research study. ↩
An individual who receives a fit note can be assessed as either ‘not fit for any work’ or ‘may be fit for work’ if certain workplace adjustments are in place, such as phased returns to work, amended duties, altered hours or workplace adjustments. ↩
Taylor, M. ‘The Taylor Review of Modern Working Practices’, 2017, https://www.gov.uk/government/publications/good-work-the-taylor-review-of-modern-working-practices ↩
Waddell, G. and Burton, A. K. ‘Is work good for your health and well-being?’, 2006, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/214326/hwwb-is-work-good-for-you.pdf ↩
Ibid. ↩
DWP and DHSC, ‘Improving Lives: The Future of Work, Health and Disability’, 2017, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/663399/improving-lives-the-future-of-work-health-and-disability.PDF ↩
Fit Notes Issued by GP Practices, England, March 2019 https://digital.nhs.uk/data-and-information/publications/statistical/fit-notes-issued-by-gp-practices/march-2019 ↩
Please note the majority of employers recruited to this study had already been involved in previous research conducted by Ipsos MORI during 2018 (see: ‘Sickness absence and health in the workplace: Understanding employer behaviour and practice’ research). ↩
Please note that individuals who had received a fit note whilst out-of-work were not recruited for this research study. ↩
See: https://www.rcot.co.uk/practice-resources/standards-and-ethics/ahp-health-and-work-report ↩
Palliative care provides relief from pain and other symptoms of serious, long-term or life-threatening illness at any stage of that illness. ↩
ANPs and GPs also assessed out-of-work patients where they explained it was important to understand the patient’s habits, routines and activities that may have a bearing on their health condition. This research focused on in-work patients hence why these findings are not included in the report. ↩
In contrast to the 6.9% of ‘may be fit for work’ fit notes issued in 2018/19 (see chapter 2.1), in this study 10 out of the 15 patients interviewed had experience of being assessed as ‘may be fit for work’ and provided with a fit note which recommended workplace adjustments. ↩
For more information on classification, please see: https://www.ipsos.com/sites/default/files/publication/6800-03/MediaCT_thoughtpiece_Social_Grade_July09_V3_WEB.pdf ↩ ↩²

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Executive Summary

Acknowledgements

The authors

Glossary and abbreviations

1. Summary

1.1 Background to Report

1.2 Methodology

1.3 Key findings

1.3.1 Chapter Three: The fit note in context

1.3.2 Chapter Four: Views on fit note extension

1.3.3 Chapter Five: Assessing fitness for work

1.3.4 Chapter Six: Views on the ‘may be fit for work’ option

1.3.5 Chapter Seven: Returning to work

1.3.6 Chapter Eight: Summary and recommendations

2. Introduction

2.1 Policy background

2.2 Research aims

2.3 Method

2.4 Interpretation and representation of qualitative data

2.5 Structure and presentation of the report

2.6 Terminology used throughout the report

3. The fit note in context

3.1 Exploring the relationship between work and health

3.2 Other forms of medical evidence

AHP Health and Work Report

Patient Care Reference in Scotland

AHPs’ reports to GPs

Attendance slips

4. Views on fit note extension

4.1 Benefits of extending fit note certification

4.1.1 Detailed and specialist advice

4.1.2 Less pressure on GPs

4.1.3 Reduced instances of fit note misuse

4.2 Perceived risks associated with extension

4.2.1 Qualifications and regulation of HCPs

4.2.2 Clinical areas of expertise

4.2.3 Fragmented communication

4.2.4 Burden on HCPs

4.3 HCPs with the skills and expertise to issue fit notes

Well placed

Mixed views

Not well placed

4.3.1 Views of patients

4.3.2 Views of employers

4.3.3 Views of GPs and ANPs

4.3.4 Views of HCPs

5. Assessing fitness for work

5.1 Circumstances that lead to a fit note being issued

Self-certification

Requesters

Long-term sickness absences

Unknown conditions

Routine patients

Emergencies

5.2 Assessment of the patient

5.3 Current barriers to effective work and health conversations

6. Views on the ‘may be fit for work’ option

6.1 HCP experiences of ‘may be fit for work’ fit notes

6.2 Patient experiences of ‘may be fit for work’ fit notes

6.3 Employer experiences of ‘may be fit for work’ fit notes

7. Returning to work

7.1 Experience of returns to work

Conversations tend to be minimal when…

Conversations tend to be more extensive when…

7.2 Employer experiences of sickness absences without fit notes

8. Summary and Recommendations

8.3 Recommendations for fit note delivery and policy implementation

8.3.1 General delivery recommendations

8.3.2 Communication and policy implementation recommendations

8.4 Further considerations

9. Appendix

9.1 Sampling and recruitment

GPs – 10 interviews

ANPs – 10 interviews

Other HCPs – 10 interviews

Employers with experience of fit notes (17 interviews)

Employers without experience of fit notes (6 interviews)

Patients (15 interviews)

Topic guides