Fit for fit notes?

TO some GPs it seemed little more than double-speak when in April 2010 the traditional ‘sick note’ yielded to the much more proactive-sounding ‘fit note’. But in reality this represented much more than just a simple name change.

Gone now are the old Med 3 and Med 5 forms to sign off patients from work, replaced by a single revised Med 3 Statement of Fitness for Work. GPs consulting with a patient off work for more than seven days must tick a box indicating that the patient is either “not fit for work” or “fit for work taking account of the following advice”. And this second option includes more tick boxes judging whether the patient might benefit from a phased return to work and/or altered hours, amended duties or workplace adaptations. The form then invites comments on the “functional effects” of the patient’s condition.

Needless to say the introduction of ‘fit notes’ was not without controversy. Among concerns was that GPs might be drawn into giving opinions beyond their clinical competency. MDDUS adviser Dr Susan Gibson-Smith said at the time: “GPs are not experts in occupational health medicine and we would caution against giving anything other than the most general recommendations for alteration to work place conditions.” There were also worries over the added time involved and how eff ective GPs could really be in getting patients back to work.

But the political will behind the changes was strong given that in the UK an estimated 300,000 people each year fall out of work and into the benefits systems because of health-related issues. Sickness absence is estimated to cost the UK economy £15 billion each year. The Government believes that GPs are well-placed to help deal with the problem.

So how effective are fit notes? In a survey conducted in 2011 on behalf of the Department for Work and Pensions (DWP), 61 per cent of GPs agreed that fit notes had improved the quality of their discussions with patients about return to work and 70 per cent agreed that fit notes helped their patients make a phased return to work.

But the GPs surveyed also expressed frustration when it came to dealing with more difficult cases, particularly involving mental health issues. Only around 20 per cent of GPs agreed that there were good services locally to which they could refer their patients for either advice or support in returning to work, with 17 per cent uncertain if any such services were available locally. Deficiencies in training were also uncovered with 89 per cent of GPs reporting that they had not received training in health and work within the past 12 months.

In 2011, Dame Carol Black and David Frost CBE were commissioned to take a critical look at sickness absence in Great Britain and in January of this year the Government published its response to the report: Health at Work – an independent review of sickness absence. Among major recommendations made in the report and accepted by the Government is the creation of a health and work assessment and advisory service to deliver a state-funded assessment by occupational health professionals for employees after four weeks on sick leave. This should relieve pressure on GPs in more long-term problematic cases requiring greater expertise in occupational health.

The Government has also agreed to revise existing DWP fit note guidance for GPs and doctors to ensure that judgments about fitness to work move away from job-specific assessments. This in part arose out of concerns that GPs were being expected to provide advice on a patient’s suitability to perform specific tasks at work. The response paper states: “We do not expect GPs to be workplace experts – employers and employees are best placed to make decisions about how the advice in the fit note could translate into changes to their specific jobs and workplaces.”

It is also recognised that GPs need more support to improve knowledge and awareness of the benefits system including information about Work Capability Assessments (WCAs). The DWP has already produced a guide to the benefits system for GPs and this will be further updated to coincide with current welfare reform. In addition the RCGP offers a half-day workshop developed in partnership with the DWP and designed to increase the knowledge, skills and confidence of GPs in dealing with clinical issues relating to work and health and ensure GPs are aware of their responsibilities in regard to fitness to work. There are also online resources for GPs (www.healthyworkinguk.co.uk).

The Government response to the Black report has been by and large welcomed. Dame Carol Black commented: “Far too many people with potentially manageable conditions - like stress or back pain - are effectively being signed off work for life, sliding from a short spell of sickness absence to a life of long-term benefit dependency. The changes being made by the government today will begin to change that.”

Leicestershire GP and occupational health expert Dr Rob Hampton is also supportive of the move as he said on the GPonline website: “At last GPs will be able to refer complex cases of sickness absence in the same way as they can seek specialist healthcare advice for their patients.”

Jim Killgore is publications editor at MDDUS