This article relates to the CQC key question: Is your practice effective?
A key part of CQC inspections of GP practices is a focus on the working-age population. As part of this, CQC asks how GP practices give people fitness for work advice to aid their recovery and help them return to work and whether the fit note (or Med 3) is used to do this.
The fit note was introduced in 2010 to change the emphasis from concentrating on what patients couldn’t do to identifying what they could do. GPs are now able to consider the ‘maybe fit’ option.
The fit note brings together clinical aspects of illness and how it affects function and the ability to work. This allows doctors to judge that a patient has some functional limitations but, with appropriate support, could return to the workplace.
The role of GPs
All GPs can provide simple fitness for work advice to help patients return to work and aid their recovery. It is then up to a patient and their employer to discuss this advice and consider possible changes.
There is a general consensus that GPs and other healthcare professionals:
- play a role in advising patients about (return to) work
- agree that (return to) work is an important health outcome for clinical management
- help patients develop a return-to-work plan
- facilitate return to work through shared decision making
- enable patients to effectively communicate with their employers.
During inspection we will ask:
'Do people receive fitness for work advice to aid their recovery and help them return to work? Is the fit note used to do this?'
To do this we will ask:
- how fit notes are used in a GP practice
- whether GPs are aware of the guidance available to them
- whether they understand the implications of the advice they offer?
Evidence to support regular work
Evidence that the right work is good for people’s health is now well established. For most people, including those who are not wholly well or fit, some kind of regular work is good for their physical health, their mental health and their overall wellbeing. Indeed most people with long term health conditions do in fact work. It is certainly true that regular work can enable people to live personally, socially and economically fulfilling lives – helping ensure their wellbeing.
If patients are likely to be absent from work, particularly if for an extended period of time, the advice their GP gives in the fit note can have a major influence on their future wellbeing.
GPs should carefully consider whether to advise a patient that they are not fit for any type of work at all as this increases their longer term health risks.
Guidance for GPs
The Department for Work and Pensions (DWP) has produced guidance for GPs on how the fit note can help GPs, patients and their employers.
This sets out how:
- GPs should
- assess a patient’s general fitness for work rather than making it job specific
- consider if a patient could do some form of work – if they cannot only then advise that they are not fit for work
- being out of work can increase long-term health risks
Around 70% of fit notes issued to patients are provided for employers. It is a primary source of shared advice to employee and employer on practical measures that might be taken to enable a return to work.
GPs may be asked to issue a fit note to support a benefit claim. The principle remains the same – the assessment is about a patient’s general fitness for work, not their previous occupation or the job they are seeking.
There are misconceptions about the fit note and how it should be used. For example:
‘Even if I think someone can do some work I issue a fit note because they tell me their benefit will be stopped and they won’t get any money.'
This is not true. A fit note allows the patient to support a claim for Employment Support Allowance (ESA) – an earnings replacement benefit claimed by working-age people with a health condition. However, if a patient is not working and does not have a fit note they can still claim Jobseeker’s Allowance (JSA).
Issuing a fit note stating a patient is unfit for work when they are capable of some type of work could mean they may not get the back-to-work support they need. They may drift further away from the labour market which might be bad for their longer term health.
Since 30 March 2015, unemployed claimants who develop a health condition can choose to continue to claim JSA for up to 13 weeks, rather than having to claim ESA. While claiming JSA they will still get job-seeking support adjusted to take account of their health condition or disability. GPs will have to provide fit notes to support these claims in the same way as ESA claims.
‘There’s no point me writing that my patient ‘may be fit’ to do some work – there are no jobs round here.'
The GP guidance suggests when the ‘may be fit for work’ box on a fit note might be appropriate and what additional advice they could give. Use the free text boxes to give advice on what the patient could do at work, rather than diagnosis and symptoms of a patient’s condition.
If someone is capable of some form of work, it’s important that they get the help and support they need to move closer to the workplace..
‘I always tick ‘unfit for work’. I’m not an occupational health specialist.’
GPs are not expected to have specialist knowledge of workplaces or occupational health. Their advice on a ‘may be fit for work’ fit note is about the functional effect of a patient’s condition on work in general. Case studies in the GP guidance, produced in conjunction with medical professionals, outline how a GP might approach issuing a fit note in different circumstances, for example:
- a delivery driver who cannot drive temporarily
- an employee needing to work from home.
Many people seeking a medical certificate are declared completely unfit. This is wholly warranted when the patient’s condition precludes any form of work, either during expected recovery time or indefinitely. However, judgements about fitness for work can be influenced by the complex and subtle relationship between doctor and patient and not just the effects of the presenting condition. Nonetheless, advice that deters patients from returning to work might not be in their best interests at all.
‘I can’t use the computer-generated fit note as it’s not available on my system.’
Since September 2014, all GP practices with GPSoC systems can access the computer-generated fit note template. This:
- saves time because the system pre-populates many of the details
- stores details on the patient record.
At present, there are no statistics for fit note usage, but IT systems can produce information on fit note issuing patterns to compare with national statistics in due course.
When filling in a fit note, doctors are asked to consider an individual’s functional capacity to return not only to their own job but to work in general. This approach opens up ways to return to work that a patient may not have otherwise considered.
A heightened focus on the importance of considering the functional effects of illness and injury and finding ways of overcoming them to restore working life enriches clinical practice and serves patients even better.
Professor Nigel Sparrow is senior national GP advisor and responsible officer at the CQC
More CQC resources
- View the full CQC Essentials series on Medeconomics
- CQC's recommended reading to help practices meet regulations and prepare for an inspection