Key Learning Points: Issuing Fit Notes

Dr Vasumathy Sivarajasingam Provides 10 Key Learning Points from Government Guidance that Extends the Power to Certify Fit Notes to More Healthcare Professionals

The ‘fit note’, also known as a Med3 form or a Statement of Fitness for Work, was introduced in April 2010 across England, Wales, and Scotland.¹ It is a form of medical evidence that is free of charge under NHS provision.^1–3 Fit notes are used by patients to:^1,2,4 

• give to employers to facilitate discussions about work
• support applications for health-related benefits through the Department for Work & Pensions (DWP)
• provide evidence of eligibility for statutory sick pay (SSP).

The latest statistics on fit notes show that their use has increased recently: 10.4% more fit notes were issued in the second quarter of 2022–2023 than in the equivalent quarter of 2021–2022 (2.68 million, up from 2.43 million).¹ 

In July 2022, to reflect the growing role of healthcare professionals (HCPs) other than GPs in the care of patients, the DHSC and the DWP implemented legislative changes that allow a wider range of HCPs to issue fit notes.² New guidance was also published to reflect the changes.³ This extension of fit-note certification to other HCPs working in primary care is supported by the Royal College of General Practitioners, and offers advantages to patients, employers, HCPs, and the healthcare system as a whole.⁵ A key benefit is the reduction of the bureaucratic burden GPs face on a daily basis; now, other HCPs can engage directly with patients on matters of work without having to reroute requests through doctors.^3,5 Other potential benefits include a faster system for patients, improved continuity of care, and greater utilisation of the skills of the multidisciplinary workforce.

This article provides information for HCPs in primary care on issuing fit notes and supporting patients’ health and wellbeing, offering 10 key learning points from Government guidance on fit notes for England, Wales, and Scotland.²

1. Know When it is Appropriate to Issue a Fit Note in Primary Care

In the UK, a fit note is a valuable tool intended to complement conversations with patients about work and health, support shared decision making, and aid their recovery.² It should also facilitate a patient’s return to work, enabling them to communicate effectively with their employers about their health.² Fit notes are evidence of a patient’s fitness for work in general, not their fitness for one specific job, and they are not intended for use in the first 7 calendar days of an absence, as patients can self-certify in this period.²

For people who are out of work, a fit note can be used to:^2,3

• support a claim for incapacity-related benefits
• justify their inability to fulfil certain requirements for benefits
• help them to discuss support for their health condition with prospective employers.

Patients Who Are Fit for Work

Fit notes are not intended to be used as evidence that a person is fit for work, and should not be given to patients who are considered fit for work following assessment.² If they or their employer requests formal confirmation of their fitness for work, arrangements must be made privately with an HCP or occupational healthcare specialist.² Regarding the small number of jobs with procedures in place for this kind of confirmation (notably, jobs involving large goods or passenger-carrying vehicles, for which the Driver & Vehicle Licensing Agency has a relevant form), the patient’s employer would likely contact an HCP to make arrangements.²

2. Understand the HCP's Role in Assessing Fitness for Work

As outlined in Government guidance, the HCP’s role is primarily to give a medical opinion about the effect of a patient’s health on their fitness for work, based on their assessment of the patient.^2,3 This assessment could be based on a consultation with the patient or, alternatively, on a written report produced by another HCP involved in the patient’s care who may be ineligible to issue fit notes.^2,3 In either case, the certifying HCP needs to have the necessary information to assess their patient’s fitness for work, which will likely involve them having access to the patient’s relevant medical history.³ 

Importantly, the HCP who certifies the fit note is accountable for it (even when basing their decision on the written report of another HCP) and responsible for the associated episode of care.³ As part of this responsibility, they are required to respond to any related information requests from employers or the DWP.³

Filling Out Fit Notes Properly

HCPs must complete a fit note either on the correct clerical paper—available to order through the DWP’s system⁶—or, in most cases, through the relevant GP computer system, with a copy sent to the patient digitally or printed and given to them in person.^2,3 It is important that fit notes are completed fully, as incomplete fit notes can cause unnecessary delays to patients’ return to work or access to benefits, in turn affecting their health, and may lead to unnecessary administrative work when the patient returns to request a new one.²

Giving Advice

As HCPs are not expected to have specialist knowledge of workplaces or occupational health, they are not obliged to suggest possible changes to a patient’s workplace or job.³ However, HCPs with relevant training or qualifications can choose to include such advice in a fit note.³ Examples of factors an HCP may wish to consider in discussions and address in their advice include:²

• stamina, mobility, agility, insight, and treatment
• the likely duration of, and any potential fluctuations in, the patient’s health condition
• the impact of any ongoing clinical management
• whether doing any work would make their condition worse.

3. Recognise and Highlight the Importance of Work for Health

Underlying the Government’s attitude to fitness for work is an acceptance that good work is beneficial for a person’s physical health, mental health, and wellbeing.^2,3,7 This is just as true for people who are not fully fit;³ research from Norway has demonstrated that supported returns to work for temporarily ill workers improve long-term occupational and health outcomes.⁸

Conversely, long periods of time not working are associated with poorer mental, physical, and economic health, as well as increased use of health services.^2,7 Prolonged absence from employment can negatively affect individuals and their families, leading to social exclusion, widened health inequalities, and financial insecurity,⁷ and evidence suggests that the longer an individual is out of work because of ill health, the less likely they are to return to employment.⁹

Perceptions about Health and Work

With this in mind, it is important to understand patients’ beliefs about health and work during the consultation, and emphasise the importance of work for their health. Box 1 highlights some helpful approaches a clinician could take when discussing work with patients.²

4. Appreciate the Difference Between ‘Not Fit for Work’ and ‘May Be Fit for Work’ 

When issuing a fit note, an HCP can indicate that a patient is ‘not fit for work’, but can also choose to advise that they ‘may be fit for work taking account of the following advice’, an option intended to support the patient to return to work with appropriate accommodations, such as a reduction in workload.^2,3 This second option allows an HCP to consider whether the person is able to do some kind of work with adjustments (not specifically relating to their current job), and give advice about the limitations of their health condition.^2,3 

If a patient is given a fit note indicating they may be fit for work but their employer cannot make appropriate accommodations, the fit note should then be treated by the patient and their employer as if it states that they are not fit for work.² The patient should still be able to access SSP in this case, but may need to seek advice from a trade union or advice centre about eligibility.^2,4 

Any patient deemed not fit for work should have their fitness for work reviewed at regular intervals,² but patients who may be fit for work may also require follow up.

5. Be Aware of Legislative Changes Related to Fit Notes

Historically, only practitioners on the General Medical Council’s List of Registered Medical Practitioners were permitted to certify a legally valid fit note, and would do so with a handwritten signature.^2,3 In April 2022, the DHSC and the DWP removed the requirement for a handwritten signature, enabling digital completion and certification, and introduced a new version of the 2017 form.² Subsequently, with effect from 1 July 2022, the DHSC and the DWP amended legislation to enable statutorily registered nurses, occupational therapists, pharmacists, and physiotherapists to certify fit notes in addition to doctors.² This legislation is permissive, however, so does not make it mandatory for these HCPs to issue fit notes.^2,3

Notably, eligible HCPs who have completed the relevant training and are working in hospitals can, and should, certify fit notes at the time of hospital discharge, and do not need to signpost patients to primary care for this reason.²

6. Assess Suitability to Certify Fit Notes on an Individual Basis

When deciding whether an eligible HCP will undertake health and work conversations and issue fit notes as part of their practice, there are several factors to take into account. An individual HCP should ensure that they have the relevant skills, knowledge, and experience, considering their scope of practice and discussing this with their employer.³ The key regulatory principles relating to these decisions are included in Box 2.³

To certify fit notes, HCPs are expected as a minimum to:³

• be currently registered with the relevant regulatory body
• have this task as an agreed part of their role
• work in line with their employer’s requirements and any contractual arrangements
• have the necessary indemnity.

When considering the addition of fit-note certification to an individual HCP’s scope of practice, it is worth bearing in mind that this is an effective way for them to demonstrate the development of their knowledge and skills.³ This may be particularly useful when they are renewing or revalidating their registration.³ 

7. Undertake Appropriate Training to Issue Fit Notes Safely and Legally

Eligible HCPs who decide to start certifying fit notes must complete the free E-Learning for Healthcare (ELFH) training module on this topic¹⁰ and undertake an initial period of structured mentorship and support from an HCP who can already certify fit notes.³ The length of this period will vary depending on the individual HCP and their own development, capability, confidence, and clinical experience.³ Any HCP who certifies fit notes must also maintain up-to-date knowledge and skills and undertake associated continuing professional development to ensure that they are delivering the best outcomes for patients.³

8. Consider the Role of the Practice Management Team

If an eligible HCP is considering taking on certification of fit notes, it is important that their employer provides opportunities for training and associated support (see Box 3), ensuring that they allow the necessary time and space during work hours for this.³ Employers may choose to incorporate the ELFH training module into their internal policies or employment terms.^3,10

When planning their workforce, employers should also be mindful to balance the benefits of sharing the task of issuing fit notes across their team with the challenges of sharing this significant responsibility (see point 9, Be Alert to the Challenges Inherent in Issuing Fit Notes).³

9. Be Alert to the Challenges Inherent in Issuing Fit Notes

HCPs may face challenges when certifying fit notes, especially if there is disagreement about their recommendations, and should be advised on patient communication, managing difficult conversations, and strategies for dealing with anyone who tries to coerce them into signing a fit note.³ This is covered in the ELFH module.^3,10 Accordingly, any HCP certifying fit notes should be supported and able to manage any pressure to act outside of their professional ethical boundaries.³ Any complaints raised by patients should be dealt with in line with the practice’s own complaints policy and procedures.³

When issuing a fit note, an HCP should have agreed with their employer that this is a part of their role, be acting in their own professional capacity and scope of practice, be involved in some way with the care of the patient or have a relevant written report by another HCP, and be able to review the patient’s medical records where necessary.³ As with any clinical assessment, HCPs should be mindful of the potential implications of undertaking this task without access to medical records.³

Any fit note certification must be in line with the requirements of a professional’s respective regulatory body and the policies and procedures of the organisation for which they work.³ HCPs may therefore benefit from referring to profession-specific regulatory standards and advice on fit notes—for example, from the Royal Pharmaceutical Society,¹¹ the General Pharmaceutical Council,¹² the Nursing & Midwifery Council,¹³ the Chartered Society of Physiotherapy,¹⁴ or the Health & Care Professions Council¹⁵—as circumstances may differ.³ 

10. Capitalise on Useful Sources of Information 

Clinicians can more effectively support their patients if they are familiar with helpful work-related guidance and sources of information for patients, carers, employers, and HCPs. Box 4 includes some examples of these.

Summary

Fit notes are a crucial way in which HCPs can assist with the day-to-day lives of their patients, and expansion of powers to the multidisciplinary team to issue fit notes is a welcome change. With appropriate training and support, more primary care practitioners will now be able to share this task with GPs, assessing their patients’ fitness for work and supporting their work lives.