Fit for work? How GPs’ decisions about fitness to work can improve health

FIT NOTES AND THE FIT FOR WORK INITIATIVE

Fit notes replaced sick notes in April 2010 with much fanfare, but there is mixed evidence as to whether substantive changes have occurred. Qualitative research suggests that some doctors have used fit notes to stress the benefits of work and that patients have stated that they do not object to such conversations. Employers have also found the detailed comments by GPs within the fit notes useful, particularly when the ‘may be fit for work’ box is ticked.³ However, the box is only ticked on 6.4% of certificates (range by practice, 1–15%)⁴ and a recent report investigating the use of fit notes concluded that while they have not achieved all their objectives, progress is being made.⁵

The launch of the Fit for Work initiative coincides with the publication of the first two studies examining face-to-face consultations involving decisions about certification.⁶–⁷ While survey, focus group, and interview studies have revealed the tensions, challenges, and anxiety for both patients and GPs during consultations about work and certification,⁸–⁹ these in vivo analyses provide additional insights into what individuals actually do, as opposed to what they say they do. While GPs have been said to offer certificates too readily, in a comparison of physical and psychosocial sickness certification consultations, patients’ with low mood often elicited offers of certification;⁷ in response, GPs often resisted, making certification subject to other conditions. Byrne et al’s study ⁶ found similar patterns of communication with considerable negotiation for patients with medically unexplained symptoms.

A number of key issues are commonly misunderstood by GPs. First, the fit note is guidance and can be ignored by the patient and employer. Secondly, the guidance provided within a fit note relates to the functional loss as a result of illness, and does not refer to the individual’s ability to carry out particular work, including their current employment. Thirdly, the ‘may be fit for work’ option is not only useful when patients need employers to make changes to working conditions; it can also be used both when an employee is concerned their employer is unlikely to allow an individual back to work and also when an individual is unemployed but might be able to obtain some kind of work. Importantly, using the ‘may be fit for work’ option does not prevent individuals from obtaining benefits.¹⁰

ADVICE FOR THOSE IN EMPLOYMENT

For those in employment, a number of scenarios are encountered by GPs. The majority of fit notes are issued without complication or significant negotiation, and for physical illness, patients often decline the offer of a fit note from a GP.⁷ Repeated certification with complex negotiations often relates to specific or non-specific musculoskeletal conditions and/or mental health problems.¹¹ While time off work can initially make sense for an individual’s wellbeing, subsequent requests for fit notes then fall into the risky period, between 4 and 12 weeks, when continuing to be off work is associated with a greatly reduced chance of ever returning to work.¹ While there is only indirect evidence, we suggest that supporting an individual to actively consider the advantages and disadvantages of work is an important role for GPs; ticking the ‘may be fit’ box and providing helpful supportive comments can sometimes be an alternative to advising that an individual has no capacity to work. This could help prevent the negative consequences of never returning to work, being signed off as medically unfit by occupational health or, for those in insecure employment, of simply being made redundant.

During the coming year, the voluntary Fit for Work² initiative will become available in most regions within England, Wales, and Scotland; it is designed to provide additional support for employed individuals at risk of long-term incapacity. Based on an occupational health model, it includes an assessment and a plan for return to work; advice is also available for GPs and employers. While there have been and will continue to be concerns regarding coercion, there is reason to be optimistic that the scheme will provide valuable support for individuals to return to work who might otherwise never work again. GPs will be able to make referrals in the near future.

DECISIONS FOR INDIVIDUALS WHO ARE UNEMPLOYED

Certification for those who are not in employment, while technically also providing guidance on whether a health condition affects ability to work, has different implications. Many individuals making first requests will already be on Job Seekers Allowance (JSA). The shift of an individual from JSA to Employment and Support Allowance (ESA) can be of profound importance to both individuals and the state. For some individuals with significant physical or mental health problems, the decision is straightforward: a 3-month certificate with helpful comments and a clear diagnosis can confirm a lack of capacity for work and eligibility for ESA; a clear response to requests for written information regarding capacity for work can also reduce unnecessary face-to-face assessments. Such individuals may well be placed in the ‘Support Group’ category of ESA and are not expected to attend work-focused interviews.

For others, capacity to work is much less certain, as are the potential harms and benefits of employment. If given ESA they may be placed in the ‘Work-Related Activity Group’ category and will be expected to attend work-focused interviews with a personal advisor. For many individuals whose capacity is limited by illness this may well provide more appropriate support for returning to work than that provided on JSA. Even individuals diagnosed with severe mental illness or long-term physical conditions may benefit from being in employment; it is also worth bearing in mind that Personal Independence Payments (PIPs), which have replaced Disability Living Allowance (DLA), can compensate for the costs of having a long-term condition or disability while continuing in or striving to obtain employment. Use of the ‘may be fit for work’ box on the fit note form is a powerful way of indicating the possibility of work. Rather than defining someone as unlikely ever to gain employment, it could generate conversations that emphasise the strengths and capacities of the individual to work in the future. However, it does have the potential to cause additional anxiety for patients if not handled sensitively, and clear reasons for why work might require support, adaptation, or a phased return should be included.