‘GPs cannot deliver fit note reform on their own’

Fit notes need backing beyond what GPs can offer if they are to support a return to work, argues Health Foundation policy and research manager Sam Atwell

Working‑age health has climbed sharply up the Government’s agenda. More than four million people are now in work with a work‑limiting health condition, and ministers are increasingly concerned about the rising cost of health‑related benefits. Against this backdrop, employment minister Dame Diana Johnson signalled in March that the Government is considering reforms to Med3 forms, better known as fit notes.

Fit notes were introduced in 2010 to replace the old ‘sick note’ system, which was criticised for offering a binary choice between staying in work and being signed off sick. The aim was to give health professionals more scope to say when someone might be fit for work with the right adjustments, and to advise employers on changes that could help them remain in or return to work.

In reality, very little has changed. Of the 11.2 million fit notes issued in 2024/25, less than 7% included advice on how a patient might return to work. The Government’s recent Keep Britain Working review argued that fit notes often create ‘distance’ between employers and employees, instead of early intervention and constructive conversation.

This is a missed opportunity. A key problem is that GPs, who still issue most fit notes, often lack the time and specialist support needed to make the system work as intended.

GPs still play a crucial role. Their relationships with patients can give them a rounded understanding of people’s lives, and allow them to offer trusted, impartial advice. But with appointments still typically lasting around 10 minutes, and fewer patients seeing the same GP consistently over time, many GPs, in practice, have limited scope to explore how a person’s health affects their ability to work.

There is also a question of training. Although recent data is limited, 2012 evidence found that only 10% of GPs in England had received work and health training in the previous 12 months. More fundamentally, useful conversations about work capacity often require knowledge of different workplaces, job demands and adjustments that goes beyond what GPs could reasonably be expected to know.

An effective system for helping people stay in or return to work will require joined-up conversations between healthcare professionals providing clinical input, employers, employees and other relevant services, such as transport or social care.

One option reportedly under consideration is shifting responsibility for fit notes away from clinicians and towards non-clinical health and work professionals. This would need careful testing to ensure decisions are informed by appropriate clinical input. But it could move the UK closer to models used in countries such as the Netherlands and Denmark, where ‘caseworkers’ play a central role in supporting returns to work.

In these systems, independent experts, employed by public bodies or third-party providers, stay in contact with the individual, identify barriers to work with clinical input where needed, triage people to services and give employers practical advice on supporting a successful return.

Both the Health Foundation’s Commission for Healthier Working Lives and the Keep Britain Working review recently highlighted caseworker models as promising, though underdeveloped in the UK. Access to workplace health support remains far lower than in many European countries. And while WorkWell pilots are testing new models of work and health advice, they are still early stage and limited to 15 areas of England, with plans to expand further in the coming years.

The challenge now is scale. Policymakers need to build capacity for caseworker support, so that conversations among employees, employers and health services are better coordinated, while retaining a clear role for clinical input.

One option for the longer term would be for fit notes to operate as referrals to independent caseworker support. In the near term, there is scope to build on co-location models that place specialist work and health advisers in GP practices and other health settings, which may require additional investment.

Whichever direction the Government takes, the lesson of recent reforms is that without addressing the lack of capacity and expertise in the system, fit notes will continue to be primarily the gateway to workplace absence, rather than a tool to prevent it.

Sam Atwell is policy and research manager at the Health Foundation