GP fit notes should be replaced by employer-funded assessment, says Government review
A Government-commissioned review has made the case for replacing fit notes with a ‘non-clinical case management service’ funded by employers, which would help ‘take pressure off GPs’.
It argued that this ‘would not replace the GP’s role’ when it comes to clinical support, but it would focus on how best to support a disabled employee or employee with a health condition ‘to thrive in work’.
The 10-month review, carried out by Sir Charlie Mayfield, was commissioned jointly by the work and pensions and business and trade secretaries, and heard from hundreds of organisations, including the RCGP and the BMA, with evidence from employers, disabled people and clinicians.
It found that one in five working-age adults are now out of the labour force – 800,000 more than in 2019 due to health reasons.
According to NICE, musculoskeletal conditions and common mental health conditions are the most frequent causes of long-term sickness absence among employees in England.
Most of the time, health remains a personal matter between the employee and the NHS, ‘only surfacing when someone goes to their GP’, the Mayfield report said.
But at this point the fit note becomes ‘central and is often problematic’ with GPs being asked to assess both treatment needs and work capacity, despite ‘most lacking occupational health training’ and time to get into ‘sufficient detail’.
According to the review, 93% of fit notes in England deem the patient ‘not fit for work’ and are ‘often extended without further consultation’, and this can be exacerbated by long waiting lists and delays in getting support, adjustments or treatment.
The report said: ‘We recommend the widespread adoption of a Workplace Health Provision (WHP): a non-clinical case management service that supports employees and line managers across the healthy working lifecycle.
‘Funded by employers and building initially from existing resources, the WHP will offer support and advice, early intervention, good case management, and targeted early-stage treatment pathways.
‘Over time, we envisage the provision becoming certified, being integrated with the NHS app and reducing – or even replacing – the need for the current fit note.’
The WHP would initially build from ‘existing provision’ already available through social prescribers, NHS work initiatives, occupational health, income protection and private insurers.
However, the report said that GPs should ‘retain overall clinical responsibility’ and should ‘remain a referral point’ where clinical support is required.
It added: ‘Our ambition is that the WHP would take the pressure off our GPs and healthcare professionals, freeing up their valuable time to be spent on diagnosing and treating patients.’
It said that GPs themselves told the review that the current fit note system is ineffective as GPs ‘often lack detailed knowledge of workplace environments’, may not have occupational health training and that long-term certification ‘drains GP capacity’.
The report added that it is ‘vital’ that GPs and healthcare professionals are ‘closely involved’ in the development of the WHP, to test different approaches, understand the impacts on the fit note, and to trial clinical oversight mechanisms which include options for second opinions.
In response to the report, the Government said it will partner with employers to ‘reshape’ how health issues and disabilities are managed in the workplace with the launch of employer-led ‘vanguards’.
The ‘vanguards’ – including employers such as British Airways, Mayoral Combined Authorities, and small and medium-sized enterprises (SMEs) – are ‘early adopters’ who will develop workplace health approaches over the next three years in light of the report.
‘Vanguards’ should also be piloting new approaches in prevention and interventions for key cohorts, such as young people with physical and mental health conditions or who are neurodivergent, or older workers with MSK, the report said.
And it added: ‘Too often, employees who develop health conditions quickly detach from their workplace, exacerbated by fear and the disconnection that comes from long periods signed off with fit notes. Instead, we want policies that maintain contact and build trust, improving return-to-work outcomes.’
The RCGP said GPs should still have the option to continue to issue short-term (up to 3 weeks) fit notes and retain some involvement in longer-term care and oversight of patients’ overall health ‘where appropriate’, as this would avoid associated bureaucracy and duplication.
RCGP chair Professor Kamila Hawthorne said: ‘With workforce and workload pressures across general practice, the responsibility associated with the issuing and management of long-term certification can consume valuable GP time, and we are not always best placed to provide the wider care, including occupational health support and communication with employers, that patients often need, so this move makes sense.
‘The college also urges Government to ensure that reforms are developed and evaluated carefully, with input from healthcare professionals, occupational health experts, and patients, to ensure that the system supports recovery, protects patient safety, and helps make best use of GP time. We stand ready to work with the Government to ensure that any future reforms to the fit note system work for GPs and patients.’
Earlier this year, Government-commissioned research found that there has been limited take up of healthcare professionals other than GPs writing fit notes since the new legislation was introduced in 2022.
It comes after the Government announced it is extending its scheme to embed job coaches in GP practices to provide intensive employment advice to 40,000 more sick or disabled people.
Nine more areas in England – including Oxfordshire, Devon, the South Midlands and West Sussex and Brighton – will be putting specialist employment advisers in GP surgeries through the Connect to Work scheme.
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READERS' COMMENTS [10]
Please note, only GPs are permitted to add comments to articles
One day we GPs are going to have had so many things removed from us that there won’t be anything left to make our role worthwhile. Be in no doubt, this is not based on a wish to lighten our burden but to remove our control and diminish our professionalism. People need trusted professionals to advise them in the widest variety of life’s crises and seasons. Pregnancy has gone, motherhood has gone, family medicine is going. I know there aren’t enough of us but this is not the solution, unless you are a bureaucracy that despises professionals and the resistance to that mindset that we bring.
Could not disagree more. This is one part of our role as GPs where we do not provide the public with any benefit as evidenced by the 1:5 working age adults unable to work due to sickness. We have a significant conflict of interest in favour of providing MED3 certificates. Refusal causes potentially irretrievable breakdown in the patient relationship and, in my experience, leads to a near 100% complaint rate.
Large swathes of society rely on the payment a MED3 certificate affords them via the DWP for their main income, often this is on parity with, or greater than they would receive, whilst working. As GPs we do not have the specialist skills of an occupational health physician, nor the time afforded to be able to make truly informed decisions about what a patient can and cannot do in either the role they currently are employed in or any potential role they will be considered for.
The public deserve a better system and taxpayers deserve greater oversight than me signing endless repeats of MED3 certificates based on online requests as I just have no place to both provide care the the unwell locally AND police a broken system of benefit entitlement.
MH Agree fully, the perverse incentive not to work by making it financially worthwhile not to work because of the range of benefits and the worsening situation regarding tax in this country started in the 1990s, arguably as a way of distorting real unemployment figures. Time should have been called on this years ago but it suited mainly conservative politicians to do absolutely nothing. It’s now being introduced when the cost of living is at its highest, and opportunities for work that pays well appear to be on the slide. I am quite reluctant to give sick notes out/deliberately keep fit notes short. All that happens is the patients will then go and see other colleagues who acquiesce.
I may well get shot down in flames but we have a real problem getting enough workers in farming and agriculture – arguably beneficial for people who find themselves with mild mental health problems to do some work in these areas rather than become long term beneficiaries
Fit notes have been a disaster waiting to happen since they were first introduced. They’re an utterly ridiculous arrangement. I was on the ‘Sounding Board’, arranged by Professor Dame Carol Black, after she had been PRCP and was appointed Tsar of Health, Work and Well-being in 2007. It rapidly became clear to me that my views were not being acknowledged and I felt I was. being used as a GP complicit with the desire to introduce Fit notes. I was arguing strongly in favour of Occupation Health Nurses working within communities, responsible to an OH Consultant, and supporting patients in their place of work, alongside employers. Very occasionally, a factual report from the GP to confirm factual details (not an opinion of work ability) might be needed. Sadly, that model was dismissed and the pressure was on to support Fit notes. Consequently, I resigned.
Whilst ‘Fit notes’ were unquestionably better for us in Primary Care than the ‘Sick notes’ they replaced, they were absolutely NOT the answer to the problem. This has been borne out by the disastrous outcome we are now facing.
Like me, the vast majority of GPs have had no training in occupational health, either at medical school or post-graduation. Furthermore, not only do we rarely fully appreciate the circumstances patients face at work, but we are biased in favour of our patients and the relationship we nuture with them over years. No GP is going to risk destroying that over a confict regarding a Fit note, yet alone the risk of our patient suing us, if we get it wrong. The system is designed to encourage people to go off work -which is the worst possible arrangement for the patient (see the work by Waddell and Burke 2006), the employer and society at large).
There are less than 60 Occupational Health Consultants in the U.K. with a population of nearly 70 million. I believe in the Netherlands, with a populatinon of only 18 million, there are over 2000 OH Consultants, AND no problem with sickness benefit.
The message is: don’t use a Rolls Royce (i.e. a GP) to plough a field -it won’t do a very good job.
Pity I wasn’t listened to nearly 20 years ago!
1st sensible thing I have heard for a while – MH (and others) are correct. We are 100% NOT Occ Health savvy. Mind you it’s so sensible it probably won’t happen!!
Too many patients come in with expectation of sign off for minor health issues especially minor Mental health complaints – with no ture way of measuring if they are too anxious to work, when in reality they are fine in almost all aspects of daily life. If you dare to say they would benefit from working they raise a complaint over you being insensitive or difficult.
We are not the police to the benefits system, and in my opinion, over 50% of current medium/long term sick notes should be scrapped as the patients involved would be able to work if they wished to, and the financial gain of benefits outweighs the effort required to work and get similar or less money.
Only those truely incapable of work should be given a note saying they are not fit to work, with everyone else a note saying they are fit to work but feel they are unable – and then the world would reblance itself.
I’ve got DOccMed so if this creates a new job for me I’ll be out of GP. Haha.
When many of those in work are on benefits and still in poverty it is not up to the health service to fix the problems of society. The economy generally needs a reset in favour of people and not corporations (not least as the corporations will otherwise run out of opportunities for more exploitation.). ”the problem with capitalism is you soon run out of other peoples money to take off them”
This has more to do with the number of people out of economic activity indicator than anything GPS might or might not do.
The ‘fit note’ is a deckchair on an ocean liner.
big mistake to get rid of Form RM7
The system makes it worthwhile to be “ill”. People play the system and GPs are caught in between a rock and a hard place. The government wants productivity but is pretentious in making “kind rules” and it has no ability to see the outcomes it want.