What has gone wrong with the Fit Note?

XpertHR has published a survey finding that satisfaction with the Fit Note is dwindling among employers. Fit notes have been in place since April 2010. They originally got a lukewarm reception and in 2011 just under half (48%) of employers felt it had been a significant improvement in managing absence. Confidence in the scheme, according to the recent results, is now down to just 38%.

So what has gone wrong with the scheme? Or has it?

In a recent speech, Dame Carol Black, who devised the Fit Note scheme, spoke positively about the progress so far. The scheme has been in place less than 3 years and more than half (53%) of GPs have received training on the Fit Note. Nearly half (48%) of GPs say the Fit Note has increased how often they advise a return to work as aid to recovery. The electronic formulation that started in July of this year was a key improvement according to Dame Carol and will allow to track and analyse the use of the fit note. She did agree that the journey is not over yet and we should focus on addressing the key challenges listed below to ensure the scheme becomes successful.

‘May be fit for work’

The core innovation of the Fit Note was the ‘may be fit for work’ option, which is aimed to reduce unnecessary sick leave and encourage discussions with the employer about what tasks the absentee could perform. This option has been used variably by GPs and the key criticism from employers is the lack of useful advice – GPs are seen as completing a tick box exercise without giving any practical recommendations. However, 56% of employers said that the Fit Note has helped with communication in some cases.

Fit for work – but for what job?

Assessing fitness to work is a challenging task for GPs who are not Occupational Health (OH) specialists and fitness to any work as opposed to fitness to do the job the individual is employed to do may be two very different things. Some of the critics of the Fit Note have been skeptical about this aspect from start: it can be challenging even for the OH Physicians to determine fitness to work but at least they are usually supported by management information about what the job role is and what adjustments may be available. For GPs to make a sufficient assessment without this information and within the very short time spent with the patient does sound ambitious.

Unfit for non-medical reasons

Comments from respondents to the XpertHR survey reveal that employers feel GPs sometimes sign employees off when they could potentially return to work. Clinicians are often seen as writing what the patient wants on the Fit Note rather than making an objective assessment. In feedback from GPs, 77% admitted that they sometimes feel obliged to write a medical note for a non-medical reason, according to Dame Carol. This practice is clearly unhelpful as actively addressing the real source of the problem would be the better way forward.

GPs reluctant to change

38% of GPs say the Fit Note has not changed their practice and Dame Carol Black was concerned that less than a quarter (23%) of practitioners have a good knowledge of the benefit system. This means the GPs fail to understand how signing an individual off work for several weeks may be the first stepping-stone on a long slippery slope toward long term unemployment. The active government support to return a person to work starts too late and if we fail to make use of the early opportunities to facilitate a return, the likelihood of a return at all quickly diminishes. As the patient’s advocate, GPs should take a long term view of the individual’s health and wellbeing.