Getting the best from the fit note

Introduction

Sickness absence costs UK employers £9 billion a year in sick pay and associated costs and the government spends £13 billion annually on health-related benefits.^[1] Unnecessary absence is known to be harmful to an individual’s health and well-being.^[2] It is therefore a priority to reduce sickness absence and work disability due to ill health and to improve the health of the working population through closer collaboration between the health and employment sectors.^[3] The Statement of Fitness for Work or ‘fit note’ is one of the main tools the government has introduced to effect this change.^[1][5]

The fit note was introduced in April 2010 to replace the previous sickness certificate and to encourage GPs to change the focus to what a patient is able to do at work. GPs can use the fit note either to advise that a patient is ‘not fit’ for work, or that they ‘may be fit’, taking into account certain advice, including: a phased return to work; altered hours; amended duties and/or workplace adaptations. The ‘fit note’ has the potential to be a significant tool in facilitating the support that people need by stimulating dialogue that can pave the way towards return to work. Fit note advice on work modifications that help patients remain in work or return to work also has the potential to control and reduce future workplace risks to health.

However, although the fit note has been broadly welcomed by GPs and employers as a way of supporting return to work and job retention in those with health problems, difficulties and uncertainties have resulted in wide variations in their use. GPs regularly report that employers fail to act on the advice given; employers often complain that GPs fail to use the fit note to provide sufficient advice. Despite such a major policy change, necessitating huge investment, no systematic approach to evaluate the fit note from the perspective of all stakeholders has been conducted. Research on fit notes to date is limited in scope and based mainly on small interview studies, questionnaire surveys of employers or reports published by the Department for Work and Pensions (DWP). No research has reported on a consensus view of the ideal content of the fit note, the factors that facilitate it, or what training is needed to improve best practice.

Research aims and objectives

This study sought to address the gaps in the current literature by investigating how the fit note is used in practice and by trying to identify how best to optimise its effectiveness in aiding work retention and return-towork from the perspective of all three main stakeholders: employer, employee/patient, GP.

The research question was: “How can fit notes best be used by employers, employees and GPs to aid return-to-work and work retention?"

The objectives were:

1. To reach a consensus on the content of the ideal fit note from the perspective of employers,

employees and GPs in order to facilitate return-to-work and work retention.

1. To produce recommendations for good practice in the completion, timing, transmission and

application of fit notes.

1. To identify acceptable methods of facilitating dialogue between these stakeholders.
2. To develop specific training for employers and GPs in the effective use of fit notes.

Background

Sickness absence in the UK

In the UK, employees who consider themselves unable to work due to a health condition can self-certify for up to 7 days. After this period, sick leave must be validated by a medical practitioner, usually a GP, in order to claim Statutory or Occupational Sick Pay, or health-related benefits. During an average week a full-time GP will sign approximately ten certificates.^[6]

Since 1970, sick leave rates have risen steeply in the UK. In 2013, 131 million days were lost to sickness absence^[7]. Nearly one million employees a year reach the four-week sickness absence point. The state spends around £12 billion a year in healthcare, sick pay reimbursement and foregone taxes, employers face an annual bill of around £9 billion for sick pay and associated costs, and individuals collectively face loss of earnings of £4 billion.^[8].

In addition to the financial consequences, sickness absence also negatively impacts on health and wellbeing. It is recognised that work has a positive impact on people’s longer term health and wellbeing and that absence from work is generally detrimental.^[9]

In order to address the escalating costs of sickness absence, and to change the prevailing philosophy that illness is incompatible with work, the government introduced a strategy for work, health and wellbeing (Health, Work and Wellbeing, caring for our future) and commissioned a review of the working age population.[9]^[10] One of the main tools designed to drive the strategy forward is the Statement of Fitness for Work, better known as the ‘fit note’, which replaced the ‘sick note’ in England, Wales and Scotland in 2010. This changed the focus to what a patient may be able to do at work rather than simply recording a yes or no judgement by the doctor.

Development of the fit note

Until the introduction of the fit note, the procedure followed by GPs, and the forms they used, had altered little since the foundation of the NHS. However, in contrast, the work and health arena had undergone considerable change,for example:

• work itself has become safer and less physically demanding
• employers are obliged to take account of disability rights legislation
• the healthcare professions have recognised their role in assisting patients to work

As a result, there has been growing recognition that medical practitioners, particularly GPs, need better support in advising their patients on returning to work. Dame Carol Black first recommended replacing the ‘sick note’ with a ‘fit note’^[1]. In response to her recommendation, the government developed a revised statement through consultation with a wide range of stakeholders including GPs, employers, health professionals and trade unions. A trial of the proposed fit note was conducted with over 500 GPs, ^[12] and following this, the government conducted a 12 week consultation on the draft changes to the regulations governing the medical certificate^[13].

The results of the consultation were published in January 2010^[2]. There was broad support for the proposed fit note, although caution was expressed particularly by trades unions. The main change made to the fit note from the draft version was that the option of ‘you are fit for work’ was removed. A sample copy of the fit note can be seen in the appendix. The electronic version of the fit note was introduced in 2012 with roll-out nationally to be completed by early 2013.

The purpose of the fit note has been described^[15] as to:

• improve return-to-work advice for individuals on a period of sickness absence
• improve communication between individuals, GPs and employers on what a patient can do and how a patient’s condition might be facilitated at work
• reduce sickness absence
• support people with health conditions stay in work or return to work more quickly
• contribute to creating new perspectives on the link between work and health and improve awareness and understanding of the importance of work for good health.

GPs can use the fit note to advise either that a patient is ‘not fit’ for work or that they ‘may be fit’. Where it is considered that a patient ‘may be fit’ for work, GPs are required to advise on one or more of four workplace modifications (phased return; altered hours; amended duties; workplace adjustments) and to provide additional comments in a free-text box including the functional effects of the patient’s condition. If the employer and employee are unable to make necessary modifications, then the ‘may be fit’ note is treated as a ‘not fit’ note, and the employee remains off sick. GPs are also required to state the duration of the fit note, either by entering an amount of time (days, weeks, months) or by specifying the date that the fit note starts and ends. In addition the GP should state whether or not they will need to assess the patient’s fitness for work again at the end of the period covered by the fit note. However, patients do not have to be reassessed by the GP prior to returning to work; the patient can return to work when they feel able, even if this is before the fit note expires, providing the employer has conducted a suitable risk assessment.

Literature review

Since the introduction of the fit note, a number of research studies have reported on its use. These studies, which have been conducted with GPs, employers and employees, have reported on data collected using both quantitative and qualitative methodologies. However, there are a number of limitations with the existing literature which are highlighted below.

Experience of the fit note – GPs

Literature reporting on GPs’ experiences of the fit note has been mainly qualitative in nature. Two of these studies^[16],^[17] had comparatively small samples, and in these cases it is unlikely that saturation would have been reached. All of the studies relied on general recall about fit notes, rather than using actual examples.

Welsh et al.conducted an interview study with 15 GPs between August and November 2010 and reported that overall the fit note was well received and many GPs felt that it facilitated an earlier return to work when used as a negotiation tool. However, other participants were sceptical. Employers were perceived as the major obstacle in the return-to-work process and that they wanted patients to be signed as ‘fit’ for work. Some GPs would have liked the option to access early independent assessments of patients’ work ability, and to receive feedback on the impact of the fit note on employees’ behaviour. Many considered this aspect of their practice to be a low priority and they lacked the time to access educational resources.

In another interview study with 13 GPs conducted between April and October 2010, Wainwright et al.also found support for the rationale behind the fit note, but again identified barriers to its use. These included concerns about the impact of the fit note on maintaining the doctor-patient relationship, inconsistent engagement from employers, GPs’ lack of occupational health knowledge, issues with training, and doubts about whether the new format could achieve the cultural shift required. Most GPs felt the fit note ‘might’ help negotiate return to work because of the extra space available for comment and that the four work modification options encouraged more in-depth thought about return to work. Others felt that it had made little change to their practice. However, this study specifically related to the use of fit notes for patients with chronic pain, four of the sample had specialist OH qualifications, and the authors acknowledged potential bias as a limitation of the study.

Fylan et al.conducted a larger interview study with 45 GPs between February and May 2011, commissioned by the Department for Work and Pensions. The authors reported that GPs found the fit note useful in initiating discussion with the patient about their potential return to work. However, barriers to successful use were again identified, including GPs’ self-efficacy in dealing with conflict, their unwillingness to damage their relationship with their patients, and the local economic and labour market conditions. Some reported difficulty in understanding and distinguishing between the modification options and confusion over date fields. Not all GPs understood the level of detail they should include on the fit note and perceived their self-efficacy in using the fit note was reduced because they receive little feedback about the usefulness of their advice.

A survey conducted in 2010 of 1,405 GPs in England, Scotland and Wales for the Department for Work and Pensions investigated GPs’ attitudes to work and health and their views about the fit note^[18]. The survey was repeated with 1,665 GPs in 2012 and the results compared^[19]. The authors reported an increase in the proportion of GPs who were positive about the impact of the fit note on patient outcomes and the quality of work-related discussion however, 29 per cent still reported that it had made no change to their practice. In 2012, as in 2010, only a very small minority of GPs had received training in work and health within the past 12 months. Those who had received training tended to report higher levels of confidence in dealing with patient issues around return to work, but there was no significant association between training and reported impacts of the new fit note.

Experience of the fit note – employers

Research studies of employers’ experiences of the fit note have also been mainly qualitative in nature. The only quantitative data has been collected by employer organisations, and obtained through annual surveys, rather than through more robust research methodologies.

In semi-structured interviews with 13 employers and 13 employees, Wainwright et al^[20] found that the fit note was perceived to be helpful if used in combination with other strategies for managing sick leave and return to work for people with chronic pain. The fit note was valued for its positive language, interrogative format and ‘biomedical’ authority. Employers liked the format, which they thought encouraged conversation between stakeholders. However, as with a previous study, this focused specifically on employees with chronic pain thus limiting generalizability.

In a study commissioned by the Department for Work and Pensions, Lalani et al. ^[21] conducted interviews with employer representatives and employees from 54 organisations of varying size. Participants included 58 Human Resources specialists, six Occupational Health specialists, 15 line managers and 11 other managers.

Although the intent of the fit note was welcomed, views as to its usefulness were varied. Some felt it had focussed attention on return to work, leading to adjustments being considered and implemented more fully, however others thought it had not changed their management approach and was irrelevant to discussions with employees.

Three UK employer organisations have also reported on the fit note from data collected in their annual survey of employers. The Chartered Institute of Personnel and Development (CIPD) conducted an on-line survey in 2013 completed by 618 respondents representing organisations of all sizes.^[22] Only 7% of respondents believed that the fit note was being used effectively by GPs. Three-quarters disagreed that the fit note had helped to reduce sickness absence levels in their organisation. Two-fifths reported that the fit note prompted conversations about absence/health between staff and line managers and just over one-fifth that it helped line managers to manage absence.

The Engineering Employers Federation (EEF) also conducted a survey in 2013 and received 353 responses from manufacturing organisations across the UK^[23]. Of these, 40% reported that employees were not returning to work earlier as a result of the fit note, compared to 26% who said they were. A greater proportion of companies felt that the fit note had not improved the advice given by GPs about employees’ fitness for work.

In the same year, in a survey of absence and workplace health, the Confederation of British Industry (CBI) received responses from HR practitioners and managers representing 153 organisations across the public and private sectors^[24]. Only one fifth of respondents reported that the fit note had helped their rehabilitation policies, or contained constructive advice. Only 17% believed that the fit note had actually changed the culture around rehabilitation and return to work.

Experience of the fit note – patients

Only two studies have reported specifically on patients’/employees’ experiences of the fit note. Both were qualitative, one being conducted mainly through telephone interviews.

Lalani et al.also conducted interviews with 87 employees from organisations of different sizes as part of their research commissioned by the Department for Work and Pensions. The employees broadly supported the purpose of the fit note, however their reports indicated variation in the content of fit note discussions with their GP. Consultations did not always include a conversation about the nature of the employee’s job and discussions about adjustments varied considerably in detail. Some employees felt empowered by the fit note in negotiating adjustments with their employer and felt that their employer had been more willing to make them, others that their health had been negatively affected by returning to work too soon.

In a survey of 1,398 employees conducted for the Department for Work and Pensions Chenery et al. ^[25] found that of those respondents who recalled a discussion about their job, 71% agreed that the fit note had been helpful and 68% that it had facilitated discussion with their employer about work modifications. However, this retrospective study relied on a long recall period and not the actual fit notes. In many cases modification were not recommended and nearly half of respondents did not discuss changes with their employer. The survey was conducted mainly through telephone interviews with employees who had received a sickness certificate in the previous 12 months.

Content of the fit note

Only two studies have reported on the content of actual fit notes.

Coole et al.^[26] reported on a service evaluation of 1,212 fit notes. This study focused on the completion of the comments section of both ‘not fit’ and ‘may be fit’ notes using content analysis. They found that there was a wide variation in the content of the comments – fourteen different categories were identified. Although most comments made some reference to the patient’s return to work, few described the functional effects of the patient’s condition as advised by DWP guidance. This study only reported on the comments section of the fit note.

In a further study commissioned by the Department for Work and Pension, Shiels et al. ^[27];^[28] reported on fit note data collected from 49 GP practices in five geographical locations. They reported that less than 12% of patients had been given ‘may be fit’ notes, and that only 6% of all the fit notes collected indicated that the patient ‘may be fit’ for work. However, use varied significantly between practices, including the use of the ‘may be fit’ option, the provision of advice, and the indication as to the need for reassessment.

Neither study differentiated between fit notes issued to patients who were in work and those who were unemployed.

Summary of literature

In summary, this review of existing literature has demonstrated that although research studies have been published about the fit note, many are not peer-reviewed (e.g. those commissioned by the DWP). The majority have reported on the perspectives of specific stakeholders, or focus on specific health conditions, or were small qualitative studies where data saturation is unlikely to have been reached. The majority were based on participant recall rather than on actual examples. The distinction between fit note use with those in work, as opposed to the unemployed was not always clear, nor whether the studies concerned ‘not fit’ and/or ‘may be fit’ notes. No studies have investigated how the fit note can be best used by all the three main stakeholders when the individual is employed – i.e. the individual, the employer and the GP, and by using mixed methods to further substantiate the findings.

Introduction to the present study

The study is presented in two phases. Ethical approval was obtained from the University of Nottingham Medical School Ethics Committee and from the Northampton Research Ethics Committee for both phases. Phase One: Study of fit notes

Actual fit note data were explored and quantitative and qualitative data were collected from participants representing the three main stakeholder groups involved:

• Employers (including human resource professionals, managers and occupational health practitioners
• Employed patients
• General Practitioners

Quantitative fit note and questionnaire data were analysed descriptively. Fit note and questionnaire comments were analysed using thematic content analysis.[26] Interview data were analysed thematically.[27]

Phase Two: Consensus study The findings from Phase One were used to conduct a modified Delphi technique to reach consensus with an expert panel of stakeholders on recommendations for best practice in fit note use. Consensus recommendations were sent to a further group of stakeholders for comment on the achievability of applying the recommendations in practice.