Who Can Issue Fit Notes: Guidance for Healthcare Professionals and their Employers

Overview

Multiprofessional working has seen some healthcare professionals (HCPs) with the relevant skills and experience support work and health conversations, but until July 2022 only doctors (registered medical practitioners) were legally permitted to certify statements for fitness to work (fit notes). The Department for Work and Pensions (DWP) amended legislation, with effect from 01 July 2022 to enable nurses, occupational therapists, pharmacists, and physiotherapists to certify fit notes in addition to doctors. These five professions are referred to in this guideline summary as HCPs.

This Guidelines summary provides advice to HCPs and their employers about certifying fit notes, providing a summary of the knowledge, skills, experience, and training HCPs are expected to have. This guidance sits alongside two other key resources:

• Getting the most out of the fit note, which covers the practical task of undertaking a health-and-work conversation and completing the fit note form
• The E-learning for Healthcare (ELFH) fit note training module, which supports HCPs in preparing to certify fit notes as part of their practice.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Legislation

• A statement of fitness for work, commonly known as a fit note or ‘med 3’, is a form of medical evidence that can enable an individual to access health-related benefits or evidence eligibility for statutory sick pay (SSP). Its purpose, format, and requirements are set out in regulations that cover England, Wales, and Scotland. The fit note contains options to assess a person as ‘not fit for work’ or ‘may be fit for work taking account of the following advice’
• The legislation requires the HCP to undertake an assessment to complete a fit note. An assessment is defined as a consultation between the patient and HCP or consideration of a written report by another health professional. The fit note provides advice about the functional effects of a patient’s condition on their fitness for work, but it does not require the HCP to have specialist knowledge of workplaces or occupational health or to suggest possible changes to a patient’s workplace or job
• Where patients are required to evidence eligibility for SSP, provided their employer is content, they can provide alternate forms of evidence. One example of this is the ‘Allied Health Professional Health and Work Report’, which can be completed by all allied health professionals, including those that are not legally able to certify fit notes.

E-learning for Healthcare Training—‘The Fit Note’

• HCPs starting to take on the task of certifying fit notes should complete the ELFH training
• The objectives of the training are to support HCPs:
  • to further develop their confidence and skills to have an effective work-and-health conversation and to be able to understand and communicate (where appropriate) the importance of work as a clinical outcome
  • to use professional judgement to assess impact of a health condition on an individual’s fitness for work
  • to be able to negotiate and develop an agreed plan with the patient about their health and work, including advice about self-management and workplace modifications (where appropriate)
  • to complete the technical steps required in the process of completing a fit note and understand options for next steps after a fit note has been certified, for example, signposting.

Eligible Healthcare Professionals

Certifying Fit Notes

• When first conducting fit-note certification, the HCPs who are legally able to certify fit notes should complete the ELFH training modules on fit-note certification and have a period of structured mentorship and support. The period of mentorship and support may be variable in length depending on the development of capability and confidence, alongside clinical experience of conversations with the person in the care of the professional about health and work, including shared decision making
• As a minimum, the HCP should:
  • hold current registration with the relevant professional healthcare regulator
  • have certifying fit notes as an agreed part of their role (if employed or operating under a contract)
  • be able to articulate that certifying fit notes is in their individual scope of practice
  • be involved with the assessment, diagnosis, or care planning of the patient the work-and-health conversation relates to, or be able to form an assessment based on a written report by another HCP
  • be acting in their professional capacity
  • work in accordance with the requirements of their employer and/or contractual arrangements
  • have necessary indemnity
  • review patient medical records where appropriate, for example, to assess the duration of health condition and likely fluctuation or treatment side effects and duration
• Individuals may also wish to consider profession-specific guidance, where it has been issued by the relevant professional body.

Relevant Experience for Certifying Fit Notes

• The length and type of experience that individual HCPs have in this area will vary. Each HCP should ensure that they have the knowledge, skills, and experience to undertake this new task in line with their individual scope of practice and be able to articulate this to their employer if it is an agreed part of their role
• HCPs are required to revalidate (renew/reregister) as a condition of their registration. This provides opportunities to demonstrate development of knowledge, skills, and a reflective account of their practice relating to certifying fit notes as appropriate. Employers who wish to include this new duty in existing or new job roles will need to consider any additional relevant work-based experience they can provide to assist their HCPs
• Opportunities to gain relevant experience could include:
  • observing an experienced HCP conducting health-and-work conversations and certifying fit notes
  • case-based discussion with a more experienced HCP until competent and confident to give feedback about health-and-work assessment and intervention, clinical reasoning, and decision making
  • structured mentorship, support, and supervision from experienced HCPs to successfully transition their knowledge into practice
  • opportunities for reflection and feedback to support their approach
  • use of daily debrief during initial period for safety and assurance
  • ongoing knowledge and skills development and working in practice
• As part of ongoing knowledge and skills development, HCPs should know when to seek the advice of colleagues and mentors about a patient’s health and work needs. For example, the relevant HCP who is certifying the fit note can, and should where needed, make use of the wider expertise of their teams to inform health-and-work conversations and decision making with regards to the fit note
• As per the legislation, the HCP certifying the fit note can do so based on consideration of a written report by another health professional involved with the diagnosis or care planning of the patient. It is not necessary for the written report to be undertaken by a member of one of the five professions currently listed in regulations (doctors, nurses, occupational therapists, pharmacists, and physiotherapists) as having the ability to certify fit notes. To note, the HCP who certifies the fit note is accountable, even when based on the written report of another health professional
• Subject to the necessary agreement of the patient, HCPs may also wish to share the information that a fit note form has been completed with other relevant professional colleagues involved in the patient’s care
  • HCPs should carefully consider with whom they share information about a patient’s fit note
  • the healthcare regulators provide guidance on patient confidentiality, including consent and implied consent, which provides useful advice on how to make a decision on the disclosure of information
  • when deciding benefit entitlement, the DWP may seek further information from professionals involved in the patient’s care. Patients give consent for this information to be provided as part of their claim, and HCPs do not need to seek additional consent
• It is recognised there may be challenges for HCPs certifying fit notes when there is disagreement about the best course of action and recommendations on the fit note. Advice on communicating with patients and handling difficult conversations is covered in the ELFH training package and in the Governance section in this summary. HCPs should not feel pressured to sign a fit note
• HCPs completing a fit note should be regarded as responsible for that episode of care, including responding to any requests for further information or evidence from the DWP or the patient’s employer for the duration of the fit note
• HCPs should always have regard to their professional accountability/responsibility, codes, and standards according to the requirements of their respective regulatory body (see the section, Governance).

Employers of HCPs Who May Certify Fit Notes

• HCPs that are able to certify fit notes may work in a wide variety of settings. For those that are employed, it is advised that a conversation takes place between the individual registrant and their employer about whether this is an acceptable part of their employment role when certifying fit notes in their employment setting, and the nature of this responsibility
• Legislation permits fit notes to be certified by certain HCPs. However, it is consistent with overarching regulatory principles of good healthcare practice and ethics for individuals and their employers (where relevant) that they must first ensure they have the relevant skills, knowledge, and experience to undertake this task.

ELFH—‘The Fit Note’

• HCPs new to the task of certifying fit notes should complete the ELFH training. As part of this, employers should consider how best to ensure relevant HCPs have the necessary time and space during work hours to undertake this training and receive any other relevant support (see the section, Eligible Healthcare Professionals, and the section, Who Should Certify Fit Notes?). Employers may explore incorporating this training module into internal policies or employment terms, depending on context
• All HCPs eligible to certify fit notes should have access to the resource, regardless of whether they have an NHS email address. Once courses are completed, the platform produces downloadable certificates that can be used to allow HCPs to evidence their completion of the training to their employers, including when taking up a role with a new employer. Additional information regarding the ELFH training can be found in the section, E-learning for Healthcare Training—‘The Fit Note’.

Who Should Certify Fit Notes?

• Employers planning their workforce should be mindful of balancing the benefits of being able to spread the task of certifying fit notes more evenly across their HCPs with the significant nature of this responsibility
• A conversation should take place with individuals whose registered profession enables them to complete this task. This should include both their responsibilities as a registered professional to work within their scope of practice (see the section, Eligible Healthcare Professionals) and the employers’ responsibilities as their employer to provide support and training. This conversation should ensure that all individual HCPs feel confident that they are working within the scope of their competency and scope of practice before asking them to take on this task, to mitigate against potential risks (see the section, Governance)
• As part of this, an employer may wish to consider:
  • the HCP’s confidence in their ability to take on this task: many HCPs will already have experience of supporting patients with work-and-health conversations or even providing advice that informs fit notes certified by doctors, whereas others—such as newly qualified HCPs—may have less prior experience and feel they need more support before taking this task on independently, so it is important to discuss with them individually
  • support within the employment setting for HCPs taking on this task: as explored in the ELFH training module, HCPs may experience challenge from patients when having fitness-for-work conversations and some may feel under pressure to certify fit notes that do not reflect their professional clinical opinion. Consider how formal or informal support could be available in the workplace, from within established supervision practices, to peer mentoring from more experienced colleagues (see the list of suggestions in the section, Relevant Experience for Certifying Fit Notes)
  • clarifying individual responsibility: the HCPs enabled by law to certify fit notes are expected to act at all times in accordance with the codes of practice or standards set out by their regulator and professional body. It is important to note that all such HCPs, if asked to take on this task, will be mindful of acting within their scope of practice (see the section, Governance,for more information) and will need to judge their suitability to respond to fit-note requests on an individual basis.

Governance

• The HCPs legally enabled to certify fit notes are subject to statutory regulation, and therefore registrants must undertake this task in a way that is consistent with their own regulator’s standards, requirements, and employing organisation’s policies and procedures
• Any eligible registrant starting to take on the task of certifying fit notes should complete the ELFH training, in line with regulatory principles relating to maintaining up-to-date knowledge and skills
• All the regulatory bodies (the Health & Care Professions Council, Nursing & Midwifery Council, General Medical Council and General Pharmaceutical Council) that oversee the professions enabled by law to certify fit notes include in their standards of practice a form of words stipulating that:
  • registrants must recognise and be able to articulate and work within their individual competence
  • registrants must keep their knowledge and skills up to date and relevant to their scope of practice
  • registrants must undertake continuing professional development.

Applying Regulatory Standards When Certifying Fit Notes

• Beyond the need to complete appropriate training ahead of undertaking new tasks, all relevant regulatory bodies include principles that are particularly applicable to taking on certifying fit notes. Employers and individual professionals should pay particular attention to the following principles:
  • competence and scope of practice—the importance of recognising and working within the limits of the HCP’s individual level of competence, knowledge, and skills, and of seeking input from appropriately qualified colleagues when needed. This principle is applicable if, for example, a patient requests a fit note due to a health condition that is not within the scope of a registrant’s clinical practice
  • person-centred care—the importance of treating people as individuals, upholding their dignity, and listening to their concerns and preferences, as well as responding honestly to their questions. This principle is particularly applicable when having a work-and-health conversation with a patient that benefits from shared understanding and joint decisions about care
  • teamwork—the importance of working cooperatively with multidisciplinary team colleagues, respecting their skills and contributions, and sharing relevant knowledge with other colleagues involved in a patient’s care. This principle is relevant because patients may have health-and-work conversations with multiple members of the clinical team, and can benefit from clear and consistent information
  • communication—the importance of communicating clearly and professionally with patients and the public, providing the information they need in a way that is easy to understand and is appropriately recorded. This is particularly relevant given that written fit notes will need to be used and understood by not only the patient involved in the fitness-to-work discussion but also their employer and others involved in implementing any advice in the note
  • confidentiality—the importance of treating all patient information as confidential and ensuring patients’ dignity and privacy. This is particularly relevant due to the wide number of settings in which health-and-work conversations may happen, and means that such a conversation should not take place unless a private place for discussion is available
  • raising concerns—the importance of raising concerns or challenging poor behaviours when patient safety is at risk, even when difficult to do so, and of contributing to a culture that allows HCPs to raise concerns safely. This is particularly relevant as registrants may be asked to certify fit notes in situations that would mean practicing beyond their role, experience, and competence, or under pressure from a patient. They should be able to confidently refuse to do this and be supported to deal with potential pressure to act outside of professional ethical boundaries.

Considerations of Employer Policies and Procedures

• It is important for HCPs and employers (where relevant) to consider practical issues that may affect registrants’ abilities to certify fit notes in a way that complies with the above regulatory principles
  • for example, in some settings, an HCP may not have access to a patient’s relevant medical history and would need to consider whether a fit note could be appropriately certified in this circumstance. In other settings, an HCP may be limited in their ability to connect with other members of the clinical team involved in a patient’s care, to the possible detriment of their ability to make a judgement about fitness to work
  • as such, it is vital that HCPs and those involved in managing and planning services consider these regulatory principles and the specific context they are operating in when making decisions about which professionals can appropriately certify fit notes to patients and service users.