Department of Primary Care and Public Health, School of Public Health, Imperial College London, London .
Roles: Academic clinical fellow in general practiceDepartment of Primary Care and Public Health, School of Public Health, Imperial College London, London .
MD, MSc, FRCP, FFOM Roles: Consultant occupational physician and visiting professor in occupational healthAlmost 95% of over 6 million fit notes issued by GPs last year advised that the patient was ‘not fit for work’ without suggesting adjustments or advice. 1 Over one-third of patients were signed off for 5 weeks or longer, by which point one-fifth are unlikely to ever work again. 2 Mental illness accounted for around one-third of all fit notes issued. Psychosocial barriers to returning to work become more established with time, from fear that work will trigger a relapse to practical issues such as taking on childcare while signed off. The premise behind replacing the sick note with the fit note over a decade ago centred on what patients can do, rather than what they cannot do, 3 to catalyse conversations between patients and employers about returning to work, with health benefits at an individual and population level. Pre-COVID, the number of fit notes issued by GPs was closer to 10 million each year, but the ‘may be fit for work with the following advice’ section was just as under-used. This likely reflects several issues, from time constraints in primary care to limitations of the fit note itself, recently highlighted in a public consultation. 4 However, with little mention of assessing fitness to work on the GP curriculum and barriers to accessing high-quality continuing professional development resources on the topic, navigating difficult grey areas around fitness for work is something most GPs will learn on the job. Certifying a patient ‘not fit for work’ is often the path of least resistance in 10 minutes. A few cornerstones from occupational medicine can provide a stronger foundation for getting the most out of a ‘fit note’ consultation in general practice.
The relationship between work and health goes both ways. Although in general work is good for health, 5 work can cause or exacerbate ill-health, and ill-health can affect the ability to work safely and effectively. An example familiar to many NHS workers is workplace stress, 6 which can exacerbate other health conditions and impact safe working. The effect of the patient’s work on their health must be explored as well as the other way around. Any work-relatedness of the patient’s ill-health must be factored into fit note advice (Box 1), to avoid a difficult-to-break cycle whereby the patient stays off work indefinitely to avoid triggers.
Is the patient’s ill-health work related?
The second aspect is the effect of health on work or ‘Fitness for Work’. This can be systematically assessed by considering the following factors for different medical conditions:
Asking about the patient’s perception of the relationship between their work and health is important in understanding psychosocial barriers that might impede a safe and productive return to work. For example, contrary to the evidence, 8 patients with back pain commonly believe that rest is the path to recovery.
There are a handful of scenarios with prescriptive guidance around fitness for work. For the most part, fitness for work is case specific, dependent on the health of the patient and their workplace demands. Understanding how a patient’s symptoms impact their functioning, with an emphasis on what they remain capable of, is key. The patient’s functional status must be compared to the demands of their job to assess their fitness for work.
GPs are not expected to have specialist knowledge of each patient’s workplace. However, taking a brief occupational history (Box 2) will help break down the patient’s working day into tasks. Finding out how their health impacts each aspect will help make use of the ‘fit for work with the following advice’ options. Some patients have clear ideas about the adjustments that would help them to keep working during a period of ill-health, while others will need more prompting to break down their workplace functioning and identify aspects where they are still capable. For example, the suggestion could be that an NHS administrator with work-exacerbated anxiety continues back-office paperwork and pauses patient-facing work, pending reassessment.
Any aspect of work the patient may be able to continue with, in the context of reduced hours, amended duties, or adaptations, is an opportunity. GPs are unlikely to be able to make detailed recommendations without the full occupational context; therefore, general advice, reflecting the discussion with the patient about their current ability in the comments box, is prescriptive enough. Since this will be read by the employer, focusing on the functional rationale for the advice suggested is most useful. The employer is not obliged to adhere to this advice, though it should trigger conversations around how to keep the patient working. It is usually in the employer’s interest to facilitate adjustments, the alternative being paying them statutory sick pay. If the employer cannot implement the adjustments, the same ‘fit note’ can be used to qualify for sick pay.
The reassessment section can be used to set a timeframe to take stock of the changes. New advice can be recommended according to progress or deterioration in health and workplace functioning since the last assessment.
Occupational Health (OH) provision has historically been excluded from the NHS. Most public-sector workers have coverage, though they often present to general practice first, in which case advising the patient to discuss a referral to OH with their manager early in their presentation is key. OH has workplace-specific knowledge and can liaise closely with the patient’s managers on a plan. Private-sector workers in larger companies are likelier to have OH coverage than those in small- and medium-sized enterprises. In certain cases of suspected occupational illness such as occupational asthma, timely specialist input can be organised from primary care if the patient does not have access to OH. Alongside limited government guidance, 9 the Council for Work and Health recently published a particularly useful guide on work modifications for the top-five fitness-to-work presentations in general practice. 10
Despite featuring on the General Medical Council’s outcome for graduates, 11 fitness to work is often overlooked in undergraduate and postgraduate curricula. Addressing this, alongside making the fit note itself more fit for purpose, will help GPs do more for their patients in this area.