Guidance

Annex C – Case studies

Updated 6 October 2023

1. Case study 1: Health consultation with a patient to discuss chronic medical condition. Healthcare professional makes recommendation to support patient back to work with support from employer.

You had a health consultation with a patient with a medical history of relatively controlled cystic fibrosis. The patient complained of a sore throat and runny nose.

Based on the patient’s treatment plan, you take a throat swab and prescribe antibiotics. During the consultation you advised the patient that they could do other types of work other than their current job role. The patient expects to be signed off work as previously done on other occasions. The patient mentioned they are looking forward to some ‘down time’ because they are feeling unwell and has to attend physiotherapist appointments. You explain that they do not need to be 100% ‘well’ to do some work. Being at work may help their recovery by providing a routine and keeping them focussed on getting better.

During the health and work discussion, you agree that they can still perform non-physical tasks. Their cystic fibrosis means they are at higher risk of secondary bacterial infection, especially in winter, as they often have to wait in the cold during their journey to work. They are worried about becoming very ill with a chest infection as had happened last year after a cold. You issue a fit note stating that they ‘may be fit’ for work, they cannot come into the office due to risk of infection, but they can work from home. You add in the comment box ‘Should avoid strenuous physical tasks as they will tire more easily’.

You do not need to specify job roles as this should be discussed by your patient and their employer. You should tick – ’workplace adjustments’ on the fit note, you specify a duration of 10 days based on your clinical judgement. You advise the patient that after the 10 days, they should be able to return to work as normal and they do not need to see them again once the fit note expires. You also mention they may be able to see another healthcare professional to undertake any future work and health assessments, i.e., physiotherapist.

The patient discusses the reasonable adjustment of working from home with their employer and they agree that they can work from home for the interim period. After 10 days, the patient’s swab was negative, and they have not developed any symptoms of a secondary bacterial infection. They recover from the cold and return to the office.

2. Case study 2: A patient out of work and claiming welfare benefits. Healthcare professional indicates ‘may be fit’ for work option to support patient back in to work.

A patient had been out of work and claiming welfare benefits, they contact the surgery to book an appointment to discuss their health condition with a healthcare professional. The patient recently had an exacerbation of Multiple Sclerosis (MS) and their medical records state that their MS occasionally relapses, with periods of good health in between.

The patient is keen to find a job and asks about work during the consultation. They seem unhappy about their recent flare-up as they think it means they will not be able to find a new job due to their health condition. During the patient’s medical examination, you find the patient has reduced power in their left arm and Romberg’s sign is positive. You then assess their general fitness for work.

On the fit note, you indicate they ‘may be fit’ for work. Your information on the fit note states ‘mild left arm weakness but this is the arm they write with. They should not do heavy lifting and needs a workstation assessment if working at a desk. They can still perform all other physical tasks and their mental capabilities are unaffected by their health condition.’ You tick ‘amended duties’ and ‘workplace adjustments. Based on your clinical judgement you then set the duration of the fit note to 3 months. At the consultation, you advised the patient to book a follow up appointment with the relevant healthcare professional if their health condition gets worse and indicate on the fit note that you do not need to see them after the fit note expires.

Your patient is offered a full-time work as a data analyst the following week. After the job offer has been made, the employer asks them about any health conditions they have, and they pass on the advice in their fit note. The healthcare professional additional information on the fit note was helpful as their employer was able to provide the patient with workplace modification - a tailored workstation and keyboard.

3. Case study 3: A delivery driver who cannot drive due to post-op instruction. Healthcare professional recommends workplace adjustment for the period.

A healthcare professional has a consultation with a patient a delivery driver who has just had laser eye surgery. Their post-op instructions include advice that they should not drive for 2 weeks. They come to see you expecting to be signed off from work for the period.

During the consultation, you advise the patient, although they cannot do a driving role, your advice on their fit note is about their general fitness for work. You explain that they would need to have a discussion with their employer on any other work they can do for the 2 weeks period whilst they recover.

The healthcare professional states ‘may be fit’ for work option and includes in the comments box, ‘Dry eyes, may experience temporary blurring of vision. Should not drive for 2 weeks. They can still perform other reasonable physical tasks. Mental function unaffected. If they use a computer, they should take regular short breaks as per standard guidance.’ You tick ‘amended’ duties. You advise the employer can treat the fit note as ‘not fit’ for work only if there is not a suitable alternative job. You advise them, you do not need to see your patient again at the end of the period because you expect them to be back to normal after this time.

The employer discusses the information on the fit note with employee, an allocates a back-office role to the patient for 2 weeks whilst the patient recuperates. After 2 weeks the patient returns to their original driving job without needing to see the healthcare professional again.

4. Case study 4: Someone who is not fit for work due to anxiety and depression.

An office worker has been feeling miserable and experiencing sleeping problems. They arrange a medical appointment with a healthcare professional.

During the consultation, based on their symptoms, the healthcare professional prescribes an antidepressant and arranges an appointment with the practice counsellor. The patient attends this appointment. The patient later disclosed to a family member that they are unable to sleep, lacks motivation and has not been into work. They also mention that they are thinking about ending their life and has a detailed plan of how they are going to do this.

You have a follow up appointment and assess that they are a risk to themselves. The patient refuses to go to A&E (Accident & Emergency) (Accident & Emergency) for an assessment, so you arrange an emergency psychiatric assessment at their home and hand over their care plan to the emergency psychiatric team.

You issue a fit note for a duration of 4 weeks and state he is ‘not fit for’ work due to anxiety and depression.

5. Case study 5: Relationship issues at work, not a medical condition but a management issue. Healthcare professional advice is to speak with employer to discuss way forward.

A healthcare professional has a consultation with a patient complaining of working relationship matters causing them stress and requests to be signed off work. During the consultation, the healthcare professional empathised about the situation at work but advised that a fit note cannot be issued as they have not got a health condition. The patient initially reacts badly to this decision, but the healthcare professional advises the patient it is not a medical problem but a management issue. The healthcare professional explained to the patient going off sick will not resolve the problem, nor help them find another job if that is what they decide to do.

The healthcare professional suggests talking to someone at work to help them resolve the problems with the manager or other resources they can use – for example speaking to Human Resources Department (HR), contacting a trade union rep, or speaking to ACAS (Advisory, Conciliation and Arbitration Service).

The healthcare professional advises the patient to book another medical appointment if they continue to feel stressed. The patient decides to remain in work and to approach another colleague at work for advice and to check the internet and ACAS for help on managing conflicts.

6. Case study 6: Short term illness due to long COVID. Occupational therapist intervention to support patient back into work.

A patient is booked to see the occupational therapist following a repeat fit note request at their GP practice. The patient, in their 30s, has been on sickness absence from their education-based role for the past two months due to a diagnosis of long COVID.

They present with symptoms of fatigue, breathlessness, and anxiety affecting activities of daily living, and quality of life. Following the assessment, the patient receives a fit note from the occupational therapist indicating they are not fit for work.

Following a further assessment, the occupational therapist and patient collaboratively agree goals and intervention that includes education, energy conservation, routine building, and coping strategies.  They then agree a new fit note indicating as may be fit for work, including recommendations of a return-to-work plan and adjustments. The advice reads “Patient is experiencing fatigue, advise a phased return to work starting at reduced hours at three days per week, suggest regular reviews before increasing. Some supportive adjustments include a quieter space to work, a quiet space for relaxation, provide additional time for administration tasks, postpone additional projects until settled into compulsory tasks of role.”  The patient, their employer, and occupational therapist also meet to agree what would be reasonable.

After six sessions of intervention the patient returns to their education-based role. At three months post discharge the patient reports they have achieved and sustained a phased return to work and continue to access supportive adjustments.

7. Case study 7: Low back pain with long term unemployment. Relevant support and recommendation from occupational therapist to help patient back into work.

A patient is seen by the occupational therapist at their GP practice with a request to review their fitness for work. The patient, in their 40s, presents with history of low back pain. They are unemployed, last working in a construction job two years ago. They have been receiving repeat fit notes indicating as not fit for work for their welfare benefit claim.

The patient explains they are interested in work but have not been able to return to a construction job and are not sure if anyone would employ them in another industry. The occupational therapist identifies that the back pain is well managed and that they function highly in activities of daily living, being mindful of any aggravators for pain and adjusting. Potential work roles the patient could consider are discussed. Education is provided on reasonable adjustments and how this can support a return to work.  On the patient’s fit note, the occupational therapist indicates may be fit for work.  The advice reads “Back pain is triggered by prolonged walking and standing, repeated bending, repeated use of stairs or ladders.  Alternative roles to construction may be more suited.  May require adjustments of seated breaks for standing tasks, reduce regular bending or use of stairs. Would require a workstation assessment if engaging in computer-based work.”

The patient is referred to a local vocational service to support searching for work and training.  They engage in a hospitality course and a part time job accessing supportive adjustments.

8. Case study 8: An employer makes workplace changes based on advice from a Physiotherapist

Your patient works as a Team Leader in a supply chain department. They visit your physiotherapy clinic complaining of knee and toe pain following a fall. You diagnose a quadriceps soft tissue tear.

You advise them on rehabilitation, formulate a treatment plan and provide them with a home exercise programme. You then move the discussion to work issues. You and your patient discuss how their injury affects their fitness for work and agree that they can still perform non-physical tasks. They are currently struggling to walk for more than 10 minutes and are unable to drive due to their injury. Nevertheless, they are keen to return to work and state that 50% of their duties are desk based.

You state on the fit note that your patient ‘may be fit’ for work and write ‘I recommend a return to work on desk-based duties,’ preferably from home to avoid driving until the patient feels able. They should then make a gradual return to their manual duties over the next six weeks.’

You do not discuss which tasks they should do from home – these discussions are for the patient and their employer. You tick ’amended duties.’ Your patient manages to complete their return to work and attends physiotherapy weekly for rehabilitation. They discuss with their employer the advice from the physiotherapy sessions to tailor their return to manual duties appropriately.

9. Case study 9: Patient who has been out of work long-term and is reluctant to return to work

A patient in their 50’s attends a physiotherapy clinic. They have suffered with chronic pain and fatigue for over fifteen years. They were diagnosed with fibromyalgia seven years ago. They have had various treatments through the NHS over the years and are currently managing with pain medication and self-management strategies.

Your patient has been unemployed for six years, due to ill health, and is in receipt of welfare benefit. Their work coach has asked your patient to look for work now that their symptoms are better managed. Your patient is worried about returning to work, especially due to their literacy skills and feels that their English is poor. Your patient would like a long-term fit note to show their work coach. You explain to your patient that they do not need to be 100% ‘well’ to work, and that working again may help them by providing a routine and keeping them focused-on symptom management.

You explain to your patient that although their flare-ups mean that at times, they will not be able to perform certain tasks, they may be able to perform others. You explain that your advice on their fit note is about their general fitness for work and that this means they can discuss lines of work suitable with their work coach. You write on the fit note that your patient is ‘very anxious about returning to work after six years of being unemployed.” Since being asked to look for work, they have experienced increased anxiety.

Following the assessment today, the key triggers seem to be their anxiety around returning to work and worries about their English reading and writing skills. You discussed their attendance at a pain management programme to help with anxiety and associated triggers. You also recommend ‘vocational support’ for their reading and writing skills over the coming months, before expecting them to return to work.’ You tick ‘a phased return to work’ and ‘workplace adaptations. You set the timescale of the fit note to 3 months and explain that your patient does not need to return unless their situation changes.

Following support with their reading and writing, your patient is offered a job as a food delivery driver 2 months later. After the job offer has been made, their employer asks them about any health conditions they have, and they pass on the advice in their fit note, along with strategies they have learnt through the pain management programme. Their employer uses this to provide your patient with tailored working hours and adaptations to support their return to work.

10. Case study 10: Pharmacist in a clinic refers patient for additional support.

You work as a pharmacist in a GP surgery. A patient with Atrial Fibrillation has a medical appointment with you to review their medication.

During this consultation, the patient informs you they were advised by the clinic that their fit note would be renewed at the appointment. They mention that they have been off work as a train driver for several months with lower back pain. Although you discuss how their back pain limits their daily activities, you explain to the patient this appointment is to review the anti-coagulation medication for Atrial Fibrillation.

You advise the patient that unfortunately you cannot issue a fit note as they need to be seen by someone who can help with their specific condition, you make a referral to another healthcare professional i.e., physiotherapist, or occupational therapist to carry out a work and health assessment and discuss the treatment plan for their ongoing back pain.

Following an assessment with another healthcare professional the patient’s treatment plan supported them back into employment.

11. Case study 11: Phased return following an acute short-term illness

Your patient has been treated by yourself, the General practice nurse for a respiratory infection. You have prescribed antibiotics and have advised the patient to rest for a week as the infection has caused significant symptoms.

You discuss work with your patient who has a physically active role. Whilst they could self-certificate for 7 days you consider the ongoing recovery required and agree the following plan with your patient. You state on the fit note that your patient ‘may be fit’ for work, which advised 14 days off work and then to return for 50% of the time for the third week and then 75% of the time for the fourth. You advise after this they should be ok to return to work.

Your patient felt relieved that they could take the time to recover, and their employer would value the clear guidance. The nurse advised that they discuss the logistics of the reduced working hours with their employer to agree a mutually suitable plan. You state that you will not need to see your patient again at the end of the period because you expect them to be back to normal after this time.

12. Case study 12: Mental health review. Healthcare professional agrees a management plan to support patient back into work.

Your patient has been referred to you for a community mental health review and you discuss their ongoing symptoms, treatment, and support. They are struggling with low mood and finding the prospect of going to work each day difficult. This is affecting their sleep pattern and their ability to focus during working hours. They have a role that needs concentration and is safety critical.

You discuss and agree a management plan that includes both pharmaceutical and non-pharmaceutical elements. You arrange to review your patient in one months’ time when you expect the treatment to have started to have some affect and issue a fit note for a month stating they will ‘not be fit’ for work.

You suggest they discuss with their employer an occupational health referral as there is likely to be some available resources via the employer as well as some work-related stress contributing to their mental health problems.

The employer makes the referral to the occupational health team which support the patient to return to work.