Getting the most out of the fit note: guidance for healthcare professionals

Question 1

What is a fit note?

Accepted Answer

A statement of fitness for work, commonly known as a fit note or ‘med 3’, is a form of medical evidence that can enable an individual to access health-related benefits or evidence eligibility for Statutory Sick Pay (SSP).

The fit note is based on an assessment by a healthcare professional about their patient’s fitness for work. Legislation requires the healthcare professional to undertake an assessment, either through a face to face, video call, telephone consultation or through considering a written report by another healthcare professional, in order to complete a fit note.

The healthcare professional responsible for the episode of care is best placed to carry out the fitness for work assessment, provide advice to the patient and issue the fit note. The fit note should cover the duration that the patient is likely to be not fit or may be fit for work and, where appropriate, provide advice for the patient and their employer to help them stay in, or return to, work.

The length of a fit note should depend on your clinical judgement, however in the first six months of a person’s health condition, a fit note can only be issued for a maximum of three months at a time. You can set a review date where required. Not issuing a fit note, or issuing one with a very short duration, can lead to unnecessary duplication of work. Issuing a fit note for longer than necessary could lead to your patient becoming inactive and they may find it more challenging to return to work.

Question 2

1.  Fit note changes

Accepted Answer

1.1 In 2022, Department for Work and Pensions implemented two significant changes. A new version of the fit note was introduced to replace the signature in ink with the name and profession of the issuer. Legislative change enabled a wider range of healthcare professionals to certify fit notes. The healthcare professionals who can now certify fit notes in addition to doctors, are nurses, occupational therapists, pharmacists, and physiotherapists.

1.2 This change recognises that healthcare professionals from a range of disciplines now play a central role alongside doctors in leading the delivery of healthcare and support for patients’ return to work, to enable them to manage their health and wellbeing. Increasingly this applies to enabling people to safely remain in or return to work wherever possible, and to manage their own health and wellbeing.

1.3 Healthcare professionals providing primary medical services under the National Health Services are required, to issue free of charge a fit note to NHS patients for whom they provide clinical care. The healthcare professional might charge a fee if the employee or employer request a fit note for 7 calendar days or less.

1.4 Healthcare professionals working in private practice or a private hospital that are not treating NHS patients will have to produce a report that includes information set out in regulations and complies with ‘the Rules’, which can then be considered ‘a form to like effect’ as a fit note.

1.5 This guidance has been updated alongside the publication of non-statutory guidance and a training package on E-learning for healthcare. We recommend, as do your professional bodies, you complete the training modules before assessing patients’ fitness for work and issuing a fit note. These resources are to be used together to support eligible healthcare professionals ensure that they have the required expertise and knowledge to be able to certify and issue fit notes.

1.6 Digital fit notes have been embedded within primary care settings (GP IT systems) and we are working towards making fit notes available within secondary care settings. In the interim, it will be necessary to continue to use the pre-printed forms supplied by DWP leaflets and how to order them. For the latest information on secondary care electronic fit note rollout contact your local IT system provider.

Question 3

2.  The role of healthcare professionals to certify fit notes

Accepted Answer

2.1 Doctors, nurses, occupational therapists, pharmacists, and physiotherapists can all provide fitness for work advice to patients, using the fit note to help patients return to employment and aid their recovery. This can be based on a written report by another healthcare professional, including those that are not eligible to certify fit notes.

2.2 A fit note for the first 7 calendar days of a patient’s sickness absence is not required as patients can self-certify for this period, this includes weekends and bank holidays.

2.3 Healthcare professionals play a key role in advising patients about how they can start, stay, and succeed in work. Being in, or returning to, work is an important health outcome for most patients. You can also facilitate return to work through shared decision making and enabling the patients to effectively communicate this with their employer. It is then up to your patient and their employer to discuss your advice and consider possible changes. The fit note is an advisory document, and the employer can decide whether to accept it.

Question 4

3.  Clinical setting

Accepted Answer

3.1 Fit notes can be issued in any relevant setting where an assessment of patients’ fitness for work is made. It is important that the healthcare professional responsible for the episode of care is the one who issues the fit note if it is within their ability.

3.2 It is important that patients are not signposted to other healthcare professionals when discharged from a hospital setting purely for the purposes of certifying a fit note. Patients who request a repeat fit note should be encouraged to see the healthcare professional responsible for their care to have a work and health conversation.

3.3 It is also possible for a fit note to be based on consideration of a written report by another healthcare professional involved with the diagnosis or care planning of the patient. This does not need to be one of the five professions listed in regulations.

Question 5

4.  Benefits of issuing fit notes

Accepted Answer

4.1 The fit note is designed to help you provide fitness for work advice to your patients. This guide will help you use the fit note to its maximum potential to improve your patient’s health and wellbeing. Using the fit note to its full potential enables you to effectively have a more rounded discussion about your patient’s capability for work. It will give a clear assessment to your patient about the impact of their condition on their fitness for work. It can also improve the likelihood of your patient keeping their job, by helping them to discuss ways they could be supported at work with their employer.

4.2 If a fit note is not completed correctly, the employer may find it difficult to support your patient and could cause unnecessary delays to your patient’s return to work, with associated consequences for their health. This can also cause additional work for you as patients ask you for new fit notes when they may not need to.

4.3 Jobcentre Work Coaches and Disability Employment Advisors use the fit note advice from the healthcare professional to support people on welfare benefits back into appropriate work or closer to the labour market.

Question 6

5.  Advantages to patients’ health of being at work.

Accepted Answer

5.1 Patient beliefs about health and work vary widely and can be explored during a consultation. As with other health advice, you should emphasise the advantages, where clinically appropriate to your patient’s health of being at work.

5.2 Sometimes, people believe work will worsen their health condition and this may create reluctance to engage in a health and work discussion. You may be able to ease any apprehension in these cases.

5.3 At other times, people may have issues at work, varying expectations of gaining enjoyable work, concern about the effects on benefit receipt or other personal problems. In these circumstances it may be in your patient’s best interest if you refer them to other available support. Where appropriate, the following approaches may facilitate your work and health conversation:

Question 7

6.  To take into consideration when carrying out an assessment.

Accepted Answer

6.1 Your assessment about whether your patient is fit for work is about their fitness for work in general and is not job specific, but you may adapt your advice when considering your patient’s situation. You do not need to issue a fit note if your assessment is that the patient’s fitness for work is not impaired by their health condition.

6.2 The fit note should be used to give advice about the functional effects of your patient’s condition on their fitness for work and you can use the comment box to give further information or detail about possible adaptations if you think this may help your patient to stay in, or return to, work.

6.3 Always consider if your patient could do other work duties or altered hours (if possible), or if they would benefit from workplace adjustments (such as working from home), before advising that they are not fit for any work. You should consider the health risks of long-term unemployment when advising your patient that they are not fit for work.

6.4 Your liability for the advice you provide goes no further than your responsibility to carry out a suitable clinical assessment of your patient’s health condition. Your patient’s employer is responsible for undertaking a suitable risk assessment to accommodate your clinical judgement.

May be fit for work advice, taking account of the following;

6.5 When stating your patient may be fit for work, use the comment box to give further information about possible adaptations or actions (such as an occupational health referral) that could support your patient to do some form of work (not specifically their current job). This gives maximum flexibility to your patient and their employer to discuss ways to accommodate your patient’s condition, use workplace modifications, which may include changing their duties for a period of time or reducing their hours to help them stay in, or return to, work.

Patients may benefit from you selecting the ‘general adaption boxes’, this may help patients and employers’ conversation.

6.6 You should use the tick boxes to indicate the kind of general adaptation that might help your patient stay in, or return to, work. Tick whichever boxes relate to the functional effects of your patient’s condition. These are not binding on your patient or their employer but help to give them a broad idea about changes to discuss. The options are:

a phased return to work: a gradual increase in work duties or hours
altered hours: changes to the times or duration of work
amended duties: changing duties to take account of a condition
workplace adaptations: changing aspects of the workplace, such as working from home

For example, if your advice is that somebody tires easily and so should not work for longer than 3 hours a day, this may affect their duties and the times they can work, you should tick ‘amended duties’ and ‘altered hours’, again with relevant comments provided.

6.7 In the first 6 months of a patient’s condition, a fit note can be issued for a maximum of 3 months. If a condition has lasted longer than 6 months, there is no limit on duration provided it is clinically appropriate. The dates are inclusive, so a fit note dated from 2 April to 10 April will no longer apply from 11 April onwards.

6.8 You should consider whether your patient’s condition would be classed as a disability under the terms of the Equality Act and provide specific advice in relation to their employer’s obligations. People who have HIV, cancer or multiple sclerosis are automatically classed as disabled under the terms of the Equality Act from the 1st day of diagnosis. For all other conditions, to count as a disability a person must experience substantial and long-term impact on their ability to do normal, day-to-day activities. Definition of disability under the Equality Act 2010

Please note: You do not need to be an occupational health expert to provide this advice, and you do not need to refer to your patient’s current job. You can describe possible adaptations if you think this would help, you should explain why this is the case, so that your patient’s employer can try to address the issue. An occupational health assessment is often helpful in these cases, this can be arranged by an employer if necessary.

Not fit for work advice, taking account of the following;

6.9 You should advise your patient that they do not need to be 100% fit to do some work.

6.10. If your clinical assessment of the patient is that they should refrain from work due to their health condition the ‘not fit for work’ box would apply. You should only tick this box if the patient cannot do any type of work. You should ensure that you continue to review their fitness for work at regular intervals.

Important: Your patient can go back to work at any point when they feel able to do so, even if this is before their fit note expires. They do not need to come back to see you in order to do so or get a new fit note. This is the case even if you have indicated that you need to assess them again in the future.

Question 8

7.  Healthcare professional guide to completing a Statement of Fitness for Work/Med 3 (fit note)

Accepted Answer

7.1 Click on the link to see step by step guide on how to complete a fit note form. Please see Annex A.

Question 9

8.  Quick reference guide for healthcare professional on completing a fit note form

Accepted Answer

8.1 A reference document has been created to highlight points to consider when issuing a fit note. Please see annex B.

Question 10

9.  Case studies

Accepted Answer

9.1 Various examples from healthcare professionals on different scenarios for ‘may be fit for work’ you may find useful. Please see annex C.

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
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
Case study 3: A delivery driver who cannot drive due to post-op instruction. Healthcare professional recommends workplace adjustment for the period
Case study 4: Someone who is not fit for work due to anxiety and depression
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 ways forward
Case study 6: Short term illness due to long COVID. Occupational therapist intervention to support patient back into work
Case study 7: Low back pain with long term unemployment. Relevant support and recommendation from occupational therapist to help patient back into work
Case study 8: An employer makes workplace changes based on advice from a Physiotherapist
Case study 9: Patient who has been out of work long-term and is reluctant to return to work
Case study 10: Pharmacist in a clinic refers patient for additional support
Case study 11: Phased return following an acute short-term illness
Case study 12: Mental health review. Healthcare professional agrees a management plan to support patient back into work

Question 11

10.  How your patient will use their fit note

Accepted Answer

10.1 If your patient is employed and you have indicated that they may be fit for work, they should discuss your advice with their employer to see if there are changes which could support them to stay in, or return to, work – for example changing their duties, adjusting work premises, or providing special equipment.

10.2 If their employer cannot make any changes to accommodate your advice, the fit note is treated as if it stated that your patient was not fit for work. Your patient should not return to you for a new fit note stating this because they do not need one.

10.3 If your patient is employed and you have indicated that that they are not fit for work, they can use the fit note as evidence to show eligibility for Statutory Sick Pay (SSP). Your patient should keep their original paper or digital fit note in case they go on to need it for benefit or other purposes (their employer may take a copy for their records).

10.4 If your patient is out of work, they can use a fit note to support a claim for health-related benefits or to show that they have been unable to fulfil certain benefit requirements.

They can also use it in any discussions with prospective employers about supporting a health condition.

Question 12

11.  Fit note related – FAQs

Accepted Answer

11.1 What should l do if someone has requested a fit note to be issued by a doctor?

Please advise the patient that other healthcare professionals are now able to issue fit notes, but they can request the fit note being issued by a doctor if this is their preferred choice and a doctor is available.

11.2 What if I am asked for a fit note saying someone is fit for work?

People do not need to be signed back to work and there is no option on the fit note to do this. When the fit note expires, your patient should return to work as normal. If they don’t feel able to go back to work, they should make a new appointment to see you.

For a small number of jobs there are existing procedures for stating someone is fit for work (e.g., the DVLA Form D4 for LGV/PCV drivers). If this is the case, your patient’s employer will contact you about this.

11.3 My patient does not work, do I need to issue a fit note?

Yes, your patient may need to provide a fit note to Department for Work and Pensions to claim health-related benefit.

11.4 Can I back-date a fit note?

Yes: in certain situations, the fit note may need to include dates which are earlier than the date of the statement.

If you are issuing a fit note based on an assessment conducted at an earlier date, you should enter the date of this earlier assessment in the date of assessment field.

If your patient’s condition has affected their function for some time without a previous fit note being issued, you must enter an estimated date that their function was affected from in the ‘this will be the case from’ field.

11.5 Can I issue a new fit note before the old one expires?

Yes – in certain situations it is possible that you might be asked for a fit note whilst the old one is still valid. Following your latest assessment of their fitness for work you may issue a new (overlapping) fit note if appropriate.

11.6 If I am completing a fit note using evidence from another healthcare professional, what should be the date of the fit note?

The assessment date would be the date that you considered a report from another healthcare professional, not the date of that report itself.

11.7 Can I issue a fit note with a future start date?

No. The date of the statement must always be the date that you issue the fit note.

11.8 My patient has 2 jobs, should I issue 2 fit notes?

No, only 1 fit note should be issued per assessment.

Your patient should show their fit note to each employer and keep hold of the original. The employer can take a copy for their own records if needed. A duplicate (clearly marked ‘duplicate’) should only be issued by you if the original has been lost.

If you use computer-generated fit notes, other staff in your practice can quickly and easily print out duplicate fit notes and thereby save you time.

11.9 What if my patient fears job loss, stigma or discrimination if I reveal their health condition (or its effect on their work functioning) on their fit note?

If you feel that revealing a particular diagnosis or limitation would harm your patient’s wellbeing or compromise their position with their employer, you can enter a less precise diagnosis on the fit note.

You can issue fit notes only to cover your patient’s own health condition. If a personal issue is causing them stress resulting in ill health, it may be appropriate to issue a fit note – this will depend on your clinical opinion.

So, for example, if someone has suffered a bereavement and you assess that they are too distressed to work, it may be appropriate to write ‘distress due to bereavement’. This should only be the case if your clinical judgement is that their fitness for work has been affected. You cannot however write bereavement as a diagnosis on a fit note. If this is not the case, you should explain to your patient that you cannot issue a fit note as they do not have a medical problem.

Many employers offer special or compassionate leave in these circumstances, and your patient may be able to discuss the issue with their line manager, HR department or trade union. If they are unemployed, they should contact Jobcentre Plus.

11.11 Do I use the fit note differently if my patient is claiming benefits?

No. Your assessment should still be based on your clinical judgement about the functional effects of your patient’s health condition, and you should issue a fit note only if your patient has a health condition which impacts on their general fitness for work.

11.12 Does the fit note need to be issued when requested by a patient?

A fit note may be issued, depending on the healthcare professional’s assessment on the patient’s fitness for work.

11.13 Do I have to confirm to an employer that I have issued a fit note?

You should not provide medical information to your patient’s employer without your patient’s consent. If an employer contacts you asking if a fit note is genuine, you may choose to check the fit note serial number and confirm to the employer that you have issued it – this does not reveal any medical information but will confirm that the fit note has been issued. The British Medical Association has issued helpful guidelines on disclosing patient information.

Question 13

12.  Further information

Accepted Answer

12.1 The patients and employees guide make clear what patients can expect from their healthcare professional – for example they should not expect a healthcare professional to issue a fit note that says not fit for work if they are fit for some work.

12.2 The employers and line managers guide explain how employers should use the advice in a fit note and that if they can’t accommodate this advice, the fit note should be treated as if it stated that the patient was not fit for work.

Question 14

Return to work support

Accepted Answer

Additional support available for healthcare professionals to refer patients to if required.

The Council for Work and Health

The Council for Work and Health – Talking Work

A guide for Healthcare Professional discussing work and work modifications with patients. The guide highlights the drawbacks of long-term sickness absence and consider options possible for the patient to be able to sustain or return to work before signing them off.

Reasonable adjustments for workers with disabilities or health conditions

Employers must make reasonable adjustments to make sure workers with disabilities, or physical or mental health conditions, are not substantially disadvantaged when doing their jobs.

Access to Work

Access to Work is discretionary grant that can provide practical and financial support to people with a disability or health condition to help them stay or return to work. The grant contributes to the disability related extra costs of working faced by disabled people and those with a health condition that are beyond reasonable adjustment, but it does not replace an employer’s duty under the Equality Act to make reasonable adjustments.

Disability Employment Advisers

Disability Employment Advisers are based in Jobcentres, and work with claimants facing complex employment situations because of a disability or health condition.

Work and Health Programme

Work and Health Programme (WHP) provides employment support, in England and Wales, primarily for disabled people and disadvantaged groups who are motivated to work and need additional support to overcome any barriers. Contact is through local Jobcentres for information and access.

Employability Partnerships (Scotland)

Scotland has a partnership for delivery of employability services which is person centred to suit the individual needs. It is not time bound, and it is open to all age.

Intensive Personalised Employment Support (IPES)

Intensive Personalised Employment Support (IPES) is a programme for disabled people with multiple barriers to employment, which can be a combination of personal and work-related, who are further away from the labour market and need more intensive support. Access to IPES ended for new referrals on 1 December 2023, but support for people currently on the programme will remain in place until 21 September 2025. Information is available through local Jobcentres.

Jobcentre

Jobcentre Plus provides services that support people of working age from welfare into work and helps employers to fill their vacancies. Find your local Jobcentre Plus Local Office

Additional Healthcare Advice

Occupational Health Advice Service

For general and professional occupational health support see links below, to discuss costs, services, and potential benefits;

Details of occupational health providers

Occupational health services are sometimes provided by NHS or local authority services. To find details of providers in your area, contact:

Commercial Occupational Health Provider Association.

NHS Health at Work Network – Support for Business

Using occupational health at work: Occupational health – Acas

Supporting organisational health and wellbeing professionals

Safe Effective Quality Occupational Health Service:

Home (salus.co.uk) (Scotland)

Guidance and support for specific conditions

Provides practical tips and advice.

Royal College of Surgeons of England – Recovering from surgery

Royal College of Psychiatrists – Work and Mental Health

Macmillan – Work and cancer

Royal College of Physicians – Upper limb disorders: Occupational aspects of management

Chartered Society of Physiotherapy – reasonable-adjustments advice

Workplace guidance – Healthy Working Lives (Scotland)

Return to employment advice

NICE guidance on long-term sickness absence and incapacity for work

HSE guide to managing sick leave and return to work gives advice to employers and managers about supporting people while on sickness absence and helping them to return to work.

Fit notes can only be issued for medical problems. If your patient is dealing with a problem that is not making them ill, they should not be issued with a fit note. However, there are resources available below to help people with a range of other issues, which you may wish to refer patients to.

ACAS – ACAS
Carers – NHS Social care and support guide, Carers Trust and Support on Care Information Scotland (careinfoscotland.scot)
Debt issues – Debt and money guide from Citizen’s Advice and National Debt line
Careers Advice – National Careers Service
Relationships – Relate
Bereavement advice – Bereavement Advice

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What is a fit note?

1. Fit note changes

2. The role of healthcare professionals to certify fit notes

3. Clinical setting

4. Benefits of issuing fit notes

5. Advantages to patients’ health of being at work.

6. To take into consideration when carrying out an assessment.