Research and analysis

Summary: Exploring perceptions and attitudes towards the extension of fit note certification

Published 4 August 2020

1.1 Overview

This research explores how different healthcare professionals (HCPs), employers and patients experience and view the current fit note process; their perceptions and attitudes towards the suitability and acceptability of extending fit note certification powers to a wider range of HCPs; as well as offering insight into the ways in which future legislative reform can be most effectively and efficiently implemented in practice. Please note, the research was conducted in 2019, i.e. prior to the covid-pandemic.

1.2 Research context

Employers, Health and Inclusive Employment directorate (EHIE) includes the cross-government Work and Health Unit, jointly sponsored by the Department for Work and Pensions and the Department of Health and Social Care. EHIE leads the Government’s strategy to support working age disabled people, and people with long term health conditions enter, and stay in, employment.

In the 2017 Improving Lives: The Future of Work, Health and Disability paper, the Government announced its commitment to extend fit note certification powers beyond General Practitioners (GPs) and hospital doctors to a wider range of healthcare professionals. This commitment arose from earlier consultation with key stakeholders which concluded that reform to fit note certification had the potential to reduce clinical and administrative burdens on GPs, improve the quality of health and work conversations and support the NHS’ multi-disciplinary approach to patient-focused clinical care.

1.3 Methodology

Between April and June 2019, Ipsos MORI conducted 68 in-depth qualitative telephone interviews with a range of different individuals, including patients, employers and HCPs working within the NHS.

To capture a range of different experiences and perceptions towards the current fit note process and proposed legislative reform, recruitment for this study was undertaken across Great Britain and from a range of different urban and rural localities. In addition, individuals were purposively recruited for their capacity to provide insight into the experiences and perceptions of:

• employers from different industry sectors with varying numbers of permanent employees working in both manual and office-based environments

• employers working at different levels of an organisation, such as line managers, business owners and HR staff

• HCPs working across the NHS who both currently assess and issue fit notes as well as those professions potentially best placed to certify fit notes in the future (please see the appendix for a further breakdown of recruited HCPs)

• patients with experience of a physical or mental health condition who received a fit note while in employment.^{[footnote 1]}

1.4 Key findings

1.4.1 The fit note in context

All of the participant groups acknowledged that good quality work can impact positively on an individual’s health and wellbeing, particularly their mental health. Work was described as providing individuals with structure, routine and purpose, as well as the opportunity to socialise with work colleagues and gain financial security. As a result, many of the participants explained that a workplace culture which provided good pay, a supportive environment, a good work-life balance and promoted a culture which valued all employees performed a critical role in promoting and sustaining good health and wellbeing in employment. HCPs appeared to particularly advocate that paid work promoted and maintained an individual’s physical and mental health and often explained that long-term sickness absences appeared to considerably reduce the likelihood that a patient would be able to successfully return to work in the future.

There was broad agreement across all of the participant groups that HCPs, employers, work colleagues, family and friends as well as the individual and wider society should support those in ill health.

The study found that individuals in poor health are able to provide their employers with other forms of medical evidence than the fit note. This included the Allied Health Professions (AHP) Health and Work Report, the Patient Care Reference in Scotland, AHPs’ reports to GPs and attendance slips. They can be provided by HCPs such as pharmacists, occupational therapists, physiotherapists and Advanced Nurse Practitioners (ANPs). The other forms were reported to provide employers and GPs with more specific and detailed advice about the nature of an individual’s health condition and the implications for the job role, that the fit note was not designed to provide. However, these were ultimately designed to support and further enhance the existing fit note process as opposed to competing with or replacing it.

1.4.2 Views on fit note extension

All of the participant groups expressed interest in, and were receptive to, proposals to extend fit note certification powers to a wider range of HCPs. Such a policy change was noted to have the potential to provide patients with greater continuity of care, to allow for the provision of more detailed fit notes and reduce current time and workload pressures on GPs. When concerns were expressed, however, these tended to centre on fears that a small number of employers and patients may not perceive fit notes written by HCPs to be valid, that the extension may potentially add to the workload burdens of additional HCPs and that current poor access to clinical records may possibly lead to the issue of multiple and duplicate fit notes.

There was nonetheless a strong sense across the participant groups that the potential benefits of the fit note extension would outweigh these risks. In many cases, these risks were often noted to be effectively mitigated through:

• ensuring that all HCPs certified to issue fit notes have the appropriate level of qualifications, skills, experience and training

• an effective communication campaign which raises awareness of the fit note reform and the capacity of a wider range of HCPs to provide valid and suitable workplace advice

• a training programme for all HCPs (including GPs) which provides an overview of the relationship between work and health, guidance on how to effectively assess fitness for work and potential workplace adjustments

• a small-scale pilot of the fit note extension with a robust evaluation to monitor its implementation and impact

• enhanced IT infrastructure which provides wider access to patient clinical records and improves communication between different HCPs

Overall, there was a broad consensus across the participant groups about the type of qualifications, skills and experience necessary to provide suitable fit notes. Importantly for this research, when prompted to think about the suitability of extending fit note certification powers to five particular healthcare professional roles, ANPs, specialist nurses in occupational health, physiotherapists, occupational therapists, pharmacists and mental health professionals, the majority were considered to be suitably qualified, knowledgeable, experienced to assess fitness for work and issue a fit note. As a result, only pharmacists were considered by most of the participant groups to not have adequate access to patient clinical records, appropriate clinical training or be working in a context which would facilitate effective assessments of fitness for work.

1.4.3 Assessing fitness for work

Over the course of the study, six different circumstances were identified which would lead to a fit note being issued, including:

• self-certification: this is when an individual requests a fit note either because they or their employer is unaware of their capacity to self-certify, or an employer wants proof of an individual’s poor health

• requesters: these are individuals who book an appointment to specifically request a fit note rather than primarily to discuss a health condition

• long-term sickness absences: these are individuals who have been assessed as not fit for work for an extended period of time and, therefore, are often updating long-standing fit notes or require reassessment

• unknown conditions: these are cases when an individual books an appointment to discuss a health complaint. In most of these cases, the necessity for a fit note arises from assessment of health and conversations about health and work

• routine patients: these are cases when individuals have a planned operation in hospital. In these cases, the fit note is often secondary to the operation itself and usually issued at a later date either by the hospital doctor or GP

• emergencies: these are cases when the individual presents symptoms that require emergency treatment, i.e. appendicitis

The majority of GPs and ANPs reported that these forms of discussions framed their healthcare assessments, enabling them to build a holistic picture of their patient. However, GPs and ANPs described how they often did not have the time to provide accurate assessments of fitness for work and this led them to frequently offer only brief and non-specific workplace advice on fit notes. Time constraints appeared to be particularly challenging when a patient did not agree with their assessment of their fitness for work. In these cases, many of the GPs often explained how they had little choice but to provide a short-term fit note and ask the patient to return to clinic for a reassessment to have more in-depth work and health conversations. Importantly for this research study, some ANPs explain that in some of these challenging cases they currently refer the patient to their GP for a second opinion of their fitness for work. They explained how this action ensured that the fit note issued best met the needs of the patient but also helped to safeguard the relationship between the ANP and the patient, so they could continue to offer treatment and care.

1.4.4 Views on the ‘may be fit for work’ option

On the whole, all of the participant groups viewed the capacity for an individual to be assessed as ‘may be fit for work’ with workplace adjustments as a positive way to support individuals to remain in or return to employment^{[footnote 2]}:

• HCPs explained that it enabled patients to benefit from the positive effects of employment as their health improved

• HCPs also indicated that it allowed individuals to adjust gradually to their usual work routines and so frequently prevented the need for further sickness absences

• employers described how workplace adjustments provided their employees with a gentler introduction to full-time work whilst enabling the organisation to continue to retain their skills, experience and productivity

• patients often described how appropriate workplace adjustments supported their longer-term recovery, particularly helping many to maintain or improve their mental health and sense of wellbeing

However, the majority of participants also expressed the need for further information and guidance about the types of suitable workplace adjustments that HCPs could recommend and how this advice could be adequately implemented at work by employers. A number of issues were highlighted by the different participant groups which help to explain why there are currently relatively few ‘may be fit for work’ fit notes which provide workplace advice:

• GPs and ANPs often explained how they deliberately keep the level of detail on fit notes vague to help facilitate conversations between their patient and employer

• GPs and ANPs expressed concern that employers may not always implement workplace adjustments flexibly and appropriately, leading their patients to have to assume duties they are not comfortable with given their health condition

• employers often require more detailed assessments of fitness for work in order to feel confident their actions will support their employers at work

• employers are sometimes unwilling to accept the risk of allowing an employee to return to work unless they have been assessed as ‘fully fit’ for work, especially those operating in manual or hazardous environments

• patients frequently described experiences of their employer being unable to understand and translate the workplace adjustments on their fit notes and, in some cases, having to regularly remind their employer of any implemented adjustments

A key finding of this research study is the current discord between the level of detail that many employers expect from fit notes and the type of detail that HCPs are able to offer. This appears to suggest that the extension of certification powers may not necessarily resolve the tensions between the needs of employers and the capacity of HCPs to provide tailored workplace advice. Consequently, alongside extending fit note certification to a wider range of HCPs, it appears important to ensure that employers have access to specialist occupational health services.

1.4.5 Returning to work

There was mixed evidence of planned and cooperative return to work processes between individuals and their employer across the interviews. When this was successfully done, employers and patients often spoke about the quality and timeliness of the contact during the sickness absence, and the importance of both parties working together to plan for returns to work. Less positive experiences of return to work appeared to frequently be the result of poor communication between the employee and their employer during periods of sickness absence. Poor communication occurred when employers lacked awareness of how to effectively manage returns to work. This often led to a lack of shared understanding between the employee and their employer about how workplace adjustments could be best implemented to support returns to work.

1.4.6 Summary and recommendations

This research indicates that the extension of fit note certification powers to a wider range of appropriate HCPs is likely to be well received by HCPs, employers and patients. The findings indicate a range of potential benefits to extending fit note certification including:

• enabling more detailed and tailored workplace advice to be provided to both patients and their employers

• reducing current time and workload pressures on GPs

• minimising duplications in effort and resources in the current fit note process

• ensuring more effective use of professional healthcare time and NHS resources

• providing a better ‘fit note experience’ for patients, employers and healthcare professionals

Overall, the research also highlights broad consensus between patients, employers and HCPs regarding the qualifications, skills and experience needed to issue fit notes. These include the necessity for HCPs to operate at an advanced level, to be registered and licensed to practise clinically, and to have received relevant training on how to assess fitness for work and complete and issue fit notes.

Despite this positive reception, a number of challenges to the successful delivery and implementation of the extension have been identified, including:

• identifying the right HCPs with the skills, competencies and experiences to certify the fit note

• poor accessibility of patient clinical records for HCPs other than GPs

• preventing HCPs assessing and issuing fit notes outside of their clinical practice or skillset

• the discord between the level of detail employers expect from a fit note, the type of workplace advice that HCPs are able and required to offer and the role of wider occupational health services

These findings raise several important recommendations that could enhance the delivery of the fit note, better standardise processes, and support the effective implementation of the policy.

The research was carried out in accordance with the requirements of the international quality standard for Market Research, ISO 20252:2012, and with the Ipsos MORI Terms and Conditions which can be found at http://www.ipsosmori.com/terms.

1. Please note that individuals who had received a fit note whilst out-of-work were not recruited to be involved in this research study. ↩

2. An individual who receives a fit note can be assessed as either ‘not fit for any work’ or ‘may be fit for work’ if certain workplace adjustments are in place, such as phased returns to work, amended duties, altered hours or workplace adjustments. ↩