The signing of fit notes has always been a controversial part of the GP role, and demand is only increasing.
The number of fit notes increased by almost 9% in the past two years, with GPs in England writing almost 9.5 million in 2018/19, compared to approximately 8.7 million in 2016/17.
As a GPwSI in health and work, I’m generally positive about the importance of work as a health outcome and the role that GPs can play in it, including by issuing fit notes. Indeed, I argued that sick notes were not a waste of GP time at the Pulse Live opening debate in 2017.
I lost, with around 65% of the audience voting that GPs should not be responsible for sickness certification, but this vote is at odds with the surveys commissioned by the Department of Work and Pensions (DWP) in 2010 and 2012, where 60% of the 1,500 GPs who responded were generally favourable to the usefulness of fit notes.
One question that no-one seems to have addressed is how useful the process of GP sickness certification is in different scenarios. It’s worth remembering that NHS Digital’s data on fit notes shows that around 60% of notes are a single one for a solitary episode.
Presumably, these are instances where the medical model applies and the patient returns to work after recovering from a defined illness. It’s hard to argue that GPs aren’t best placed to issue sickness certification for these cases.
The problem arises where the requests to be signed off work continue for weeks, months or even years. The further a patient is from employment, the more uncomfortable we feel. In my decade of speaking about better use of fit notes, I’ve noticed consistent themes – 80% of GPs are ‘uncomfortable’ signing fit notes for people in the welfare system.
However, the same percentage is ‘comfortable’ with them for those in employment. This 80/20 split was confirmed in last month’s survey of the Society of Occupational Medicine GP interest group.
The ‘fit note folder’ sees a good deal of activity, and generates angst between patients and receptionists, but doesn’t seem to open opportunities for vocational rehabilitation
My Pulse Learning modules suggest how to improve confidence in sickness certification and provide understanding of our role amid the benefits process. However, I don’t believe that providing notes where someone is stuck in the benefits system should be part of a GP’s role at all.
When I talk to people in Jobcentres and patients receiving note after note, it’s clear that there’s little consistency or understanding as to how those notes makes a difference to the patient journey.
As a portfolio GP working in various practices, I see how most repeat fit notes are managed as an admin process, with no meaningful interaction between doctor and patient. The ‘fit note folder’ sees a good deal of activity, and generates angst between patients and receptionists, but doesn’t seem to change anything for the patient journey or open opportunities for vocational rehabilitation. So why are we still doing it?
The conflict GPs face when balancing our advocacy role with responsibility for sickness certification for people stuck in the benefits system was recently illustrated by Pulse. A proposed change of wording to the ESA65B letter, to suggest we don’t give fit notes to people appealing DWP decisions, attracted understandable criticism from the BMA and the RCGP. In the current system, refusing sickness certification can leave vulnerable patients at risk.
However, arguments about the wording on this letter aren’t addressing the issue for the beleaguered GPs represented by those organisations. If they really want to support their colleagues, the real issue to address is whether GPs should be asked to sign fit notes in any circumstance for people in dispute with the DWP.
Removing fit notes from this scenario completely would avoid the ethical dilemma we face over ESA65B. The caveat, of course, is to ensure there’s no financial detriment to claimants during this period.
The time is right for this issue to be addressed. The DWP and Department of Health and Social Care’s Work and Health Unit is reviewing the use of the fit note, with discussions about whether to extend the signing of the Med3 to other healthcare professionals. Furthermore, surveys frequently criticise GPs’ usage of sickness certification.
If we move to a world where fit notes are only issued in the early stages of sickness absence, could we refocus on better practice if unburdened from the churn of certification beyond? I believe we could, and should.
Dr Rob Hampton is an occupational physician, founder of the Society of Occupational Medicine’s GP interest group in health and work and portfolio GP in Leicestershire
You can join the interest group here.