Employers debate progress of fit notes after one year in use

When it was launched one year ago the "fit note" was meant to cure one of the biggest headaches for HR managers. No longer would employees be signed off for weeks with no explanation or be allowed to slip into long-term sickness absence. But has the fit note lived up to employers' hopes? Recently a group of experts on work and health gathered for a roundtable debate on the topic, organised by occupational health provider AXA PPP Healthcare and Personnel Today.

On this page:
How has the fit note been received?
What challenges has the fit note faced?
What lessons have been learnt?
When will the electronic fit note be introduced?
How will the fit note fare in the future?.

GPs believe that they are getting to grips with the aims of the fit note, according to a survey published by the Department for Work and Pensions (DWP) at the beginning of April.

The survey shows that 70% of GPs agree that the fit note has helped their patients make a phased return to work and just under half (48%) agreed that the new system had increased the frequency with which they recommend return to work as an aid to patient recovery.

But GPs are only part of the solution and the roundtable debate shows that employers, including HR, still have some way to go in developing the capability to manage sickness absence effectively. The participants in the survey were occupational health and HR experts, including Dr Bill Gunnyeon, the senior civil servant responsible for the introduction of the fit note.

You can listen to highlights of the debate - "The fit note one year on" - in a podcast from AXA PPP (external website).

How has the fit note been received by employers, employees and GPs?

Dr Bill Gunnyeon, chief medical adviser and director of wellbeing at the DWP.

Dr Bill Gunnyeon, chief medical adviser and director of health and wellbeing at the DWP, said: "What made a real difference was partnership working. The fit note was developed in partnership with employer bodies and with GP bodies. The guidance, before we launched the fit note, was done in conjunction with those bodies as well, and indeed the guidance that we've produced for individuals and patients was worked on jointly with the TUC and with the Royal College of General Practitioners patient partnership group. That's what helped smooth the introduction."

Claire Walker, reward and benefits manager at Barclays Bank, said: "The pivotal point was getting the GP gatekeeper onboard - at last they were giving the same message that 'work is good for you' that we were putting out through occupational health. Consistency of messaging actively encouraging people to be back at work was very welcome.

"At the moment very few of our fit notes are coming through that are at odds at all with our existing occupational health advice. So it's a very low level awareness but it is gradually building a momentum. It isn't a significant change for us because it is absolutely consistent with what we are doing through occupational health. We knew it wasn't going to be a revolution overnight."

Dr Steve Boorman, director of health and safety and chief medical adviser, Royal Mail - and author of the Boorman report on sickness absence in the NHS (external website) - said: "We changed our HR systems because we wanted to be able to collect the data and understand what was coming in and also to understand how successful we were going to be in terms of accommodating people where adjustments had been made. So that's allowed us to build a database over the last year in terms of 48,000 or so fit notes that have come in."

What challenges has the fit note faced since its launch?

Gunnyeon: "It was challenging trying to get the right messages across against an often hostile media and this feeling that all the Government wanted to do was to force people back to work. Having employer bodies, GP bodies, the TUC engaged helped because it's possible then to send out balanced messages."

Dr John Chisholm, council member of the Royal College of General Practitioners, member of the Council for Work and Health and the National Stakeholder Council for Health, Work and Wellbeing, said: "Early rehabilitation isn't there for all who need it. The evidence is that if access to therapy or rehabilitation is delayed, the risks of long-term worklessness are increased. [This] really is an NHS issue and an issue that may, in part, be addressed by the way in which services are commissioned. But obviously it's quite difficult to address at a time where the Nicholson challenge is requiring efficiency savings [David Nicholson, chief executive of the NHS has called for between £15 billion and £20 billion efficiency savings (on The Telegraph website) over three years from 2011].

"[SMEs] have far less opportunity to access occupational health services. Also they have, in reality, less opportunity to respond to some of the recommendations that a general practitioner may make because of lack of capacity within the organisation. Now one of the good short-term initiatives that's been set up is the Occupational Health Advice Line for SMEs (external website) and that would be something that might be continued."

What lessons have been learnt about returning employees to work from sickness absence since the launch of the fit note?

Dr Paul Litchfield, chief medical officer and head of health and safety at British Telecom, said: "When you're talking to a line manager who's doing a home visit the natural thing to do is to say 'Ok, do your home visit a few days after the person's been to see the GP to find out what's gone on.' That's wrong.

"You should be encouraging [the line manager] to do the home visit a few days before they see the GP so you can start having a discussion with the individual about the adjustments that we as an organisation would expect to make to help you get back into work. If we take a passive role and just say 'Well what's your GP said to you?' then you just build in delay and it's a less productive consultation [between the employee and the GP]."

Walker: "Hopefully, the positive statement about return to work will help facilitate that dialogue [between the employee and line manager]. Previously, the sick note prevented that dialogue because the individual was allowed to hide behind [the sick note] and therefore, as employers, we couldn't help facilitate the dialogue. We're all desperate to make sure that dialogue is happening earlier on in the process."

Boorman: "One of our examples is often quoted where we received a fit note that said 'May be fit subject to a change of manager.' That was a helpful piece of information because it allowed us to start to resolve the workplace conflict. So, although it's often taken out of context as a daft example, it was very useful.

"One of the things from our experience is that, where an adjustment is recommended, virtually everyone is able to return to work. But interestingly, in over half of the cases where the fit note has recommended an adjustment, just simply having the dialogue with the manager is enough for the individual to return to unmodified work. And it's just setting up that dialogue and opportunity that's the most important thing."

Dr Mark Simpson, medical director of occupational health services at AXA ICAS, said: "The fit note offers an opportunity for less passivity on the terms of patients who often said 'Well I've been signed off - what else can I do?' And I think it should perhaps change it to a much more interactive process. One year on, did we make enough of that opportunity? Because perhaps the one group that we didn't engage with was patients in terms of briefing them on this change."

When will the electronic fit note be introduced and what benefits will it have?

Gunnyeon: "The software [provider] Connecting for Health is leading that project across Great Britain. They now have sent out the specification to the six [GP] software providers. In terms of timescale, it would be good if we were able to introduce it later this year. It may slip into next year.

"It will remove any doubts about [deciphering the doctor's notes]. Secondly, it will be in the patient record and the big advantage of that is the continuity of care because, if you see a different GP two weeks later they will know not only that you had a fit note issued but what was said on it. Thirdly, it will mean that GPs can audit their certification practice. It's the one bit of clinical practice which they can't at the moment audit and of course it's a bit of practice that can have a huge impact on patients' lives.

"It will be possible for anonymised data to be extracted (or that's the hope) that would allow us to get some better quality information, not so much on the certification practice itself but there's a huge lack of real quality data on the causes of sickness absence - why people are signed off."

How will the fit note fare in the future?

Bevan: "If you go 20 years into the future and the history of this period is written, I think that the fit note will be seen as having contributed to a tipping point.

"It is welcome that we now have work as an outcome in the NHS Outcomes Framework. That should progressively make much more difference to the legitimacy of seeing work as a positive clinical outcome that GPs and others need to focus on.

"[In response to the Government's absence review being led by Dame Carol Black, national director of work and health and David Frost, director general of the British Chambers of Commerce,] I'd say 'Hoorah' that at last we've got the Department for Business Innovation and Skills involved in this debate because they've been stubbornly behind the curve on this for a long time as a department that has the policy lead for labour productivity in the UK.

"One of the big issues I haven't really seen addressed is how employers are going to be supported in helping to accommodate people back into work once they're judged fit for work and when they're given a pathway back into work - either through case management or through other mechanisms. I still think there's a big capability problem in many organisations - not just small ones."

The debate was chaired by Dr Mark Simpson, medical director of occupational health services at AXA PPP Healthcare, and Noel O'Reilly, editor of Occupational Health magazine.