Tag: Healthcare

This guidance is to help doctors, nurses, occupational therapists, pharmacists, and physiotherapists to make the best use of the fit note to support the health and wellbeing of patients.

It gives you information on completing each section of the fit note, including the reassessment box, comments section and return to work tick boxes, and uses illustrative case studies to give real world examples.

Changes to the fit note

From 1 July 2022, legislative change has enabled a wider range of healthcare professionals to certify fit notes. The healthcare professionals who can now certify fit notes in addition to doctors are nurses, occupational therapists, pharmacists and physiotherapists. This change is targeted at those providing relevant NHS services.

To support the new professions this guidance has been updated alongside the publication of non-statutory guidance and a training package on E-learning for healthcare. These resources are to be used together to support eligible healthcare professionals ensure that they have the required expertise and knowledge to be able to certify and issue fit notes.

In April 2022, a new version of fit note was introduced to replace the 2017 version – this replaced the signature in ink with the name and profession of the issuer. IT systems in primary care will auto populate this information but in secondary care it will be necessary to continue to use the pre-printed forms supplied by DWP leaflets and how to order them and to add your name and profession in the appropriate space.

There will be a transitional period during which both the 2017 and 2022 versions of the fit note forms will be legally valid whilst relevant IT systems are updated and stocks of paper fit notes in hospitals are replaced.
 

Context and reason for the legislative change

It is generally accepted and there is evidence ^{[footnote 1] [footnote 2] [footnote 3] [footnote 4] [footnote 5] [footnote 6] [footnote 7]} that good quality work is good for physical health, mental health and wellbeing. Evidence^{[footnote 8]} indicates that the longer someone is off work due to ill health, the less likely they are to return to employment. There is also strong evidence that long periods out of work are associated with poor mental and physical health, increased use of health services and poverty. Even if people are not fully fit, engaging with work can deliver health benefits.
 
Until now fit notes could only be certified and issued by registered medical practitioners. This change recognises that healthcare professionals from a range of disciplines now play a central role alongside doctors in leading the delivery of healthcare and support for patients to enable them to manage their health and wellbeing. Increasingly this applies to enabling people to safely remain in or return to work wherever possible, and to manage their own health and wellbeing.

It is also recognised that as part of multidisciplinary teams there are a wider range of other healthcare professionals that can support patients return to work. In these situations, doctors, nurses, occupational therapists, pharmacists and physiotherapists can use a written report from another healthcare professional to assess a patient’s capability to work and issue a fit note.

Key messages

Your assessment about whether your patient is fit for work is about their fitness for work in general and is not job-specific.

If you assess that your patient’s fitness for work is not impaired by a health condition, they are fit for work and do not need a fit note.

Always consider if your patient could do work of some kind before advising that they are not fit for any work. Remember the long-term health risks of worklessness when advising your patient that they are not fit for work.

You should use the fit note to give advice about the functional effects of your patient’s condition on their fitness for work in general. You are not expected to have specialist knowledge of workplaces or occupational health, and you do not need to suggest possible changes to your patient’s workplace or job.

When stating a patient may be fit for work you should tick whichever return to work boxes relate to your advice. Use the comments box to give further information. If you do have specialist occupational health knowledge you can go into further detail about possible adaptations if you think this would help.

Fit notes can be completed and sent digitally, or a copy printed and handed to patients if you have access to relevant GP IT systems. If required, clerical fit notes pads or sheets can still be ordered through the DWP ordering websites, for further information see DWP leaflets and how to order them.

Healthcare professionals providing primary medical services under the National Health Services Acts are required, under the Social Security Acts, to issue free of charge a fit note (Statement of fitness for work) to patients for whom they provide clinical care.

The benefits of using the fit note to its full potential

The fit note is designed to help you provide fitness for work advice to your patients. This guide will help you use the fit note to its maximum potential to improve your patient’s health and wellbeing.

In particular, using the fit note to its full potential enables you to:

• effectively manage your patient’s expectations about their capability for work
• give a clear clinical assessment to your patient about the impact of their condition on their fitness for work
• improve the likelihood of your patient keeping their job, by helping them to discuss ways they could be supported at work with their employer
• support the vital role that work can play in your patient’s health, as set out in the evidence behind the fit note

On the other hand, incomplete fit notes can make it hard for employers to support your patient and cause unnecessary delays to your patient’s return to work, with associated consequences for their health. They can also cause additional work for you as patients ask you for new fit notes when they may not need to.

The role of healthcare professionals to certify fit notes

Doctors, nurses, occupational therapists, pharmacists, and physiotherapists can all provide fitness for work advice to patients using the fit note to help them return to work and aid their recovery. This can be based on a written report by another healthcare professional, including those that are not eligible to certify fit notes.

It is then up to your patient and their employer to discuss your advice and consider possible changes.

There is a general consensus that healthcare professionals:

• play a key role in advising patients about work and return to work
• agree that work and return to work is an important health outcome for clinical management
• facilitate return to work through shared decision making
• enable patients to effectively communicate with their employers

Supporting clinical management

Work is now recognised as an important health outcome. Healthcare professionals may:

• discuss fitness for work with your patients where appropriate
• consider if they may be fit for some work
• complete all relevant sections of the fit note, to provide as much useful advice as possible to your patient and their employer
• in particular, complete the comments box with advice on the functional effects of your patient’s health condition
• consider your own training needs on health and work, and build your knowledge of other support and resources

Clinical setting

Fit notes can be issued in any relevant setting where an assessment of patients’ fitness for work is made. It is important that the healthcare professional responsible for the episode of care is the one who issues the fit note if it is within their ability. It is critical that patients are not signposted to other healthcare professionals purely for the purposes of certifying a fit note where this is avoidable, such as part of hospital discharges.

Access to the fit note as set out in regulations is limited to those providing relevant NHS services. Mainly this is eligible professionals with access to general practice IT systems or those working in other settings where they can order pads of fit notes directly from Department for Work and Pensions.

It is also possible for a fit note to be based on consideration of a written report by another healthcare professional involved with the diagnosis or care planning of the patient. This does not need to be one of the five professions listed in regulations.

Do you need to issue a fit note? How do you assess a patient’s fitness for work?

If you assess that your patient’s fitness for work is not impaired by their health condition, they are fit for work and do not need a fit note. This is the default position for all patients.

You also do not need to issue a fit note for the first 7 calendar days of a patient’s sickness absence. Patients can self-certify for this period.

If you assess that your patient’s health affects their fitness for work, you should give them a fit note indicating whether your patient is not fit for work OR may be fit for work.

Assessing your patient’s fitness for work

Your assessment about whether your patient is fit for work is about their fitness for work in general and is not job-specific. The following factors may be useful when making this assessment:

• any functional limitations of your patient’s health condition. The duration of their health condition and any likely fluctuation and whether doing any work – not necessarily their current job – will make their health condition worse. For example:
  • stamina e.g. better in the morning or the afternoon
  • mobility e.g. walking, bending, stooping
  • agility e.g. dexterity, posture, co-ordination
  • insight or stability e.g. mental state, mood
  • treatment e.g. side-effects, duration of
  • intellectual e.g. cognitive abilities
  • sensory e.g. hearing, vision, touch
• the duration of their health condition and any likely fluctuation
• the impact of any ongoing clinical management
• whether doing any work – not necessarily their current job – will make their health condition worse

Deciding between ticking may be fit for work or not fit for work

May be fit for work taking account of the following advice

Your patient may be fit for work, taking account of your advice about the functional effects of their condition.

You should tick this box if your patient could do some form of work (not specifically their current job). This gives maximum flexibility to your patient and their employer to discuss ways to accommodate your patient’s condition, which may include changing their duties for a while or reducing their hours.

For example, a delivery driver who cannot drive may still be able to do other tasks and so may be fit for work – as described in case study 4.

Not fit for work

Your patient is not fit for work of any kind.

You should tick this box only if your patient cannot do any form of work at all. Always consider if your patient could do work of some kind. Assessing that your patient is not fit for work when there are still things they can do risks depriving them of the chance to discuss ways they could do some work with their employer; and increases the long-term health risks of worklessness.

If you assess that your patient is not fit for any work, make sure that you continue to review their fitness for work at regular intervals.

See case study 5 for an example of a situation when it may be appropriate to assess that someone is not fit for work of any kind.

You now need to fill in the rest of the fit note. See Filling in the fit note for advice on how to do this.

Discussing patient beliefs about health and work

Patient beliefs about health and work vary widely and normally become apparent during a consultation. As with other health advice, you should emphasise the advantages to the patient’s health of being at work. This information will not always be embraced enthusiastically.

Sometimes, reluctance to consider work stems from a belief that work will exacerbate the health problem or delay recovery, or that patients always need to be fully fit before they return to work. You may be able to ease any apprehension in these cases.

At other times, people may have issues at work, low expectations of gaining enjoyable work, concern about the effects on benefit receipt or other personal problems. In these circumstances it may be in your patient’s best interest if you refer them to other available support.

Where appropriate, the following approaches may help in discussing work with your patients:

• discussing the health benefits of work, and the health risks of not working
• explaining that people do not need to be 100{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} fit to do some work
• issuing fit notes for shorter periods of time
• using the fit note to actively engage patients in goal setting
• telling your patient about other support services if they have non-medical issues that are affecting their attitude towards work
• specialist occupational health services can help address complex issues at work, including if your patient’s work may be affecting their health

Filling in the fit note: instructions for completion

If you assess that your patient is not fit for work, or may be fit for work (see advice on making this assessment), you will need to issue them with a fit note.

From April 2022 GP IT systems are being updated with a new fit note template. This change will mean the fit note captures the name of the doctor issuing the form in place of it being signed in ink. Fit notes can still be printed and the issuer’s name completed by hand if necessary.

While the update is taking place the existing fit note template (MED 3 01/17) must still be used and as long as it is signed in ink is legally valid.

Fit note issued without signature in ink (Med3 2022 template)

You can issue a fit note on the day that you assess your patient; or on any day afterwards.

The fit note should be completed as follows:

1. The date on which you assessed your patient. This can be via either:

• a face-to-face or telephone consultation
• consideration of a written report from another doctor or healthcare professional (for example, nurses, occupational therapists, physiotherapists)

2. Describe the condition or conditions that affect your patient’s fitness for work. Give as accurate a diagnosis as possible, unless you think a precise diagnosis will damage your patient’s wellbeing or position with their employer.

3. Tick not fit for work, or may be fit for work, taking account of the following advice – advice on making this assessment.

4. The comments box must be completed when you tick may be fit for work, and may be useful to complete when you have ticked not fit for work. See giving advice in the fit note for more information.

5. Indicate the period that your advice applies for. This may be the date that you expect your patient to have recovered by, or your judgement about an appropriate time to review their fitness for work even if they are unlikely to have fully recovered.

You can either:

• specify a period from the date of the assessment (as entered in box 1) e.g. this will be the case for 2 weeks; or
• specify a particular start and end date. e.g. this will be the case from 5 May to 19 May.

In the first 6 months of a patient’s condition, a fit note can cover a maximum of 3 months. If a condition has lasted longer than 6 months, a fit note can be for any clinically appropriate period up to ‘an indefinite period’.
The dates are inclusive, (so a fit note dated from 2 April to 10 April will no longer apply from 11 April onwards).

6. This section is mandatory – it gives your patient an indication about whether they can expect to be fit for work when the fit note expires, which helps them and their employer plan for the future. If you expect that your patient will be fit for work at the end of their fit note, indicate that you will not need to assess them again. If you don’t expect them to be fit for work, or you aren’t sure, indicate that you will need to assess them again.

7. Please insert the name of the issuer. If you are using the computer-generated fit note, this will be completed automatically by your IT software. If not, ensure that this section is filled in.

8. Please insert the profession of the issuer.If you are using the computer-generated fit note, this will be completed automatically by your IT software. If not, ensure that this section is filled in.

9. Complete the date of statement. This is the date that you issue the fit note – which may not necessarily be the same as the assessment date in box 1.

Fit note with signature in ink (Med3 2017 template)

Complete sections 1 to 6 as above.

7. Sign the fit note using ink. If you are using the computer-generated fit note, the statement date and address of your practice will be completed automatically by your IT software. If not, ensure that these sections are filled in. If you are a nurse, occupational therapist, pharmacist or physiotherapist, you must strike out ‘doctors’ and replace with your own profession.

8. Complete the date of statement. This is the date that you issue the fit note – which may not necessarily be the same as the assessment date in box 1.

GP computer generated fit notes

Most fit notes are produced through GP IT systems, but they can be handwritten, system generated and printed, or system generated and sent digitally. System generated fit notes have the added benefits of:

• automatically completing certain parts of the fit note to save you having to fill them in each time you issue one
• automatically including the name of the health professional completing the fit note to authorise it, removing the need to print and sign the fit note in ink
• ensuring that your advice is easy to read for patients and employers
• removing the need for you to re-write fit notes if duplicates are required, as other staff members can print out duplicate copies
• enabling clinical management and fitness for work advice to be monitored together for patients with long-term conditions
• improving the continuity of patient care generally – for example if patients are seen by different healthcare professionals
• allowing you to share knowledge and learning points with colleagues in your practice by carrying out appropriate internal audits

All GP practices have access to computer generated fit notes.

Giving advice in the fit note – the comments box

The comments box must be completed when you have assessed your patient as may be fit for work, and can be useful to complete when you have assessed them as not fit for work.

You should use the free text section to give advice about the functional effects of your patient’s health condition, and tick boxes to provide an overview of the factors your advice covers.

The free text section

The important information to include in this box is advice about the functional effects of your patient’s condition on their fitness for work. Your patient and their employer should then discuss possible adaptations and changes to accommodate your advice.

Your advice should focus on what your patient can do at work rather than their diagnosis and symptoms. It is helpful to give advice that is as practical as possible. See some examples in the checklist opposite.

You do not need to be an occupational health expert to provide this advice, and you do not need to refer to their current job. If you do have occupational health expertise or information about your patient’s job, you can describe possible adaptations if you think this would help. But remember not to be too prescriptive and inadvertently reduce your patient’s potential to be able to return to work.

Otherwise, the only reference to your patient’s current job should be if you feel that it may be affecting their health. In these cases, you should explain why this is the case, so that your patient’s employer can try to address the issue. An occupational health assessment is often helpful in these cases.

The checklist below may be useful when considering what to include in the comments box:

• are there things your patient cannot do in terms of mobility, strength and fitness? e.g. ‘avoid kneeling and squatting or cannot lift heavy objects’
• are there types of activities that should be avoided or altered? e.g. ‘removal of tasks which cause emotional distress or avoid driving’
• how long is this likely to be the case, or will it be permanent? e.g. ‘condition expected to improve within 2 months’
• will medical appointments be needed during working hours? e.g. ‘will need to attend physiotherapy for 1 hour twice a week’
• are there features of the workplace which may impact the patient’s condition? e.g. ‘their chair may be aggravating their back condition’
• could they benefit from an occupational health assessment?
• is there return to work guidance available from Royal Colleges or other groups on your patient’s specific condition or operation?

Your liability for the advice you provide goes no further than your responsibility to carry out a suitable clinical assessment of your patient’s health condition. Your patient’s employer is responsible for undertaking a suitable risk assessment to accommodate your clinical judgment.

The tick boxes

You should use the tick boxes to indicate the kind of general adaptations that might help your patient return to work. Tick whichever boxes relate to the functional effects of your patient’s condition. These are not binding on your patient and their employer, but help to give them a broad idea about changes to discuss. The options are:

• a phased return to work: a gradual increase in work duties or hours
• altered hours: changes to the times or duration of work
• amended duties: changing duties to take account of a condition
• workplace adaptations: changing aspects of the workplace

For example, if your advice is that somebody cannot use their right arm, this may impact on the tasks they can perform and they may need physical changes in the workplace, so you should tick ‘amended duties’ and ‘workplace adaptations’ and them explain in the comments box so the employer will understand what they can and cannot do.

If your advice is that somebody tires easily and so should not work for longer than 3 hours a day, this may affect their duties and also the times they can work, so you should tick ‘amended duties’ and ‘altered hours’, again with relevant comments provided.

The fit note in action section has examples of using the comments box to its full effect.

How your patient will use their fit note

If your patient is employed and you have indicated that that they are not fit for work, they can use the fit note to claim sick pay. Your patient should keep their original fit note in case they go on to need it for benefit or other purposes (their employer may take a copy for their records).

If your patient is employed and you have indicated that they may be fit for work, they should discuss your advice with their employer to see if there are changes which could support them to return to work – for example changing their duties, adjusting work premises or providing special equipment.

You do not need to suggest any of these changes, although you can if you believe it may help guide the conversation. Your advice is purely on the impact of your patient’s health condition and it is up to your patient and their employer to discuss ways to accommodate it.

If their employer cannot make any changes to accommodate your advice, the fit note is treated as if it stated that your patient was not fit for work. Your patient should not return to you for a new fit note stating this because they do not need one.

If your patient is out of work, they can use a fit note to support a claim for health-related benefits or to show that they have been unable to fulfil certain benefit requirements.

They can also use it in any discussions with prospective employers about supporting a health condition.

The fit note in action shows how patients can use the fit note in a variety of different situations.

There is more information about the role of employers and the benefits system in additional questions, and specific guidance on the fit note for patients and employers.

There is a short guide the benefit system for GPs available. Information about benefits for patients is available, or can be found on the back of the fit note.

The fit note in action – case studies

These illustrative case studies show how you can use the fit note to help patients in a number of situations.

Case study 1: An employer makes changes based on your advice

Your patient works for a publisher and has relatively mild cystic fibrosis. He visits you complaining of a sore throat and runny nose. You diagnose the common cold and having consulted his treatment plan, take a throat swab and prescribe antibiotics. You then move the discussion to work issues.

Your patient expects to be signed off work as he has been on other occasions, and says he is looking forward to some ‘down time’ because he’s ill and will be spending time and energy on physiotherapy.

You explain that he does not need to be 100{fe463f59fb70c5c01486843be1d66c13e664ed3ae921464fa884afebcc0ffe6c} ‘well’ to do some work, and that it will not damage his health – it may actually help his recovery by providing a routine and keeping him focussed on getting better. Keeping in touch with the office and doing some work will also make his eventual transition back to full time work easier.

You and Your patient discuss how his health affects his fitness for work, and agree that he can still perform non-physical tasks. His cystic fibrosis means he is at higher risk of secondary bacterial infection, it is the middle of winter, his commute is very crowded and he often has to wait in the cold. He is worried about becoming very ill with a chest infection as he was last year after a cold.

You state on the fit note that Your patient may be fit for work and write ‘cannot come into the office as he is at risk of infection, but can work from home. Should avoid strenuous physical tasks as he will tire more easily’.

You do not discuss which tasks he should do from home – these are discussions for him and his employer to have. You tick ’workplace adjustments’.

You set the duration of the fit note to ten days. Because you think that his employer can expect him to return to his previous function after this time, you indicate that you do not need to see him again once the fit note has expired.

Your patient calls his employer, and discusses your advice with them. His employer agrees that they will email him some work to do and he should work from home for the next ten days. He is not recorded as being on sick leave and so keeps his full pay and stays in touch with work.

After ten days, Your patient’s swab was negative; he has not developed any symptoms of a secondary bacterial infection and has recovered from his cold. He goes back to work without coming back to see you.

Case study 2: Someone who is out of work

Your patient is out of work and visits you with a recent exacerbation of multiple sclerosis (MS). His records indicate that his MS occasionally relapses, with periods of good health in between.

He is keen to find a job and asks about work during the consultation. He seems despondent about his recent flare-up as he thinks it means he won’t be able to find a new job until he is better.

You explain to your patient that although his flare-up means he won’t be able to perform certain tasks while it lasts, he may well be able to perform others.

You find that your patient has reduced power in his left arm and Romberg’s sign is positive. You also use your own knowledge of MS and the side-effects of his medication to assess his general fitness for work.

You indicate on your patient’s fit note that he may be fit for work. Your advice reads ‘Mild left arm weakness but this is the arm he writes with. Should not do heavy lifting, and needs a workstation assessment if working at a desk. Can still perform all other physical tasks and his mental capabilities are unaffected by his health condition’. You tick ‘amended duties’ and ‘workplace adjustments’. You set the duration of his fit note to 3 months.
You explain to your patient that you will leave it to him to come back and see you if his condition worsens, and indicate that you will not need to see him again after his fit note expires.

Your patient is offered a job as a data analyst the following week. After the job offer has been made, his employer asks him about any health conditions he has and he passes on the advice in his fit note. His employer uses it to provide your patient with a tailored workstation and keyboard.

Case study 3: A delivery driver who can’t drive

Your patient is a delivery driver for a major logistics firm. He has just had laser eye surgery and his post-op instructions include advice that he should not drive for 2 weeks. He comes to see you expecting to be signed off from work.

You explain to your patient that, although he can’t do his driving role, your advice on his fit note is about his general fitness for work. You explain that this means he and his employer can discuss whether he could do something else. You explain that if there isn’t another role for him, they can treat the note as a not fit for work note.

You use the comments box to write ‘Dry eyes, may experience temporary blurring of vision. Should not drive for 2 weeks. Can still perform other reasonable physical tasks. Mental function unaffected. If he uses a VDU he should take regular short breaks as per standard guidance’. You tick ‘amended duties’.

You state that you will not need to see your patient again at the end of the period because you expect him to be back to normal after this time.

Your patient and his employer discuss your advice. Although your patient should not drive, his knowledge of the company and its operations means they decide to use him in a back office role for the 2 weeks.

Your patient therefore retains his full pay, and keeps in the routine of working. After 2 weeks he goes back to work as normal without coming back to see you.

Case study 4: Someone who is not fit for work

Your patient works for an accountant, and comes to see you with his wife. His sleep has been poor for a month or two and he has been feeling hopeless and miserable. You prescribed an antidepressant for him and referred him to the practice counsellor when he attended 2 weeks ago. For the last week he has been unable to sleep, lacks motivation and has not been into work.

This morning he disclosed to his wife that he is thinking about committing suicide and has a detailed plan of how he is going to do this. You assess that he is a risk to himself. He refuses to go to A&E for an assessment so you arrange an emergency psychiatric assessment at his home and hand over his care to the emergency psychiatric team.

He is unfit for work. You indicate on his fit note that he is not fit for work due to depression and complete a fit note for 4 weeks.

Case study 5: Relationship issues at work

Your patient comes to see you, complaining that she does not get on with her manager, she is feeling very stressed and asks to be signed off work. During the consultation you determine that although her situation is upsetting her, she does not have a mental illness and she is fit for work.

You explain to your patient that you can see that she is being affected by her situation at work. However, because she does not have a health condition, you cannot issue her with a fit note. Your patient initially reacts badly, and tells you that her manager has been really horrible to her and she is finding it difficult to cope.

You agree that although this may well be the case, the situation is not making your patient ill. You reassure her that if it was, you would issue her with a fit note and that you are acting with her health interests in mind. You explain that this is not a medical problem but a management issue. Going off sick will not resolve the problem, nor help her find another job if that is what she decides to do.

You discuss whether she can talk to someone at work to help her resolve her problems with the manager or if there are other resources she can use – for example speaking to Human Resources (HR), contacting a trade union rep or speaking to ACAS. Your patient decides to approach another colleague at work for advice tomorrow, and to check the internet and ACAS for help on managing conflicts at work tonight. You ask your patient to come and see you again if she carries on feeling stressed.

Additional questions

General

What should l do if someone has requested a fit note to be issued by a doctor?

Please advise patient that other healthcare professionals are now able to issue fit notes, but they can request the fit note being issued by a doctor if this is their preferred choice and a doctor is available.

What should l do if my system has not yet been updated?

Please continue to issue fit notes using the existing templates ensuring it is ‘signed in ink’. The current template will be replaced when your IT supplier updates your system.

What if I am asked for a fit note saying someone is fit for work?

People do not need to be signed back to work and there is no option on the fit note to do this. When the fit note expires, your patient should return to work as normal. If they don’t feel able to go back to work, they should make a new appointment to see you.

For a small number of jobs there are existing procedures for stating someone is fit for work (e.g. the DVLA Form D4 for LGV/PCV drivers). If this is the case, your patient’s employer will contact you about this.

Otherwise, if your patient or their employer requests that your patient is formally signed off as fit for work, they need to make a private arrangement with a healthcare professional or occupational health specialist.

Can I back-date a fit note?

Yes: in certain situations, parts of the fit note may need to include dates, which are earlier than the date of the statement.

If you are issuing a fit note based on an assessment conducted at an earlier date, you should enter the date of this earlier assessment in the date of assessment field.

If your patient’s condition has affected their function for some time without a previous fit note being issued, you must enter an estimated date that their function was affected from in the ‘this will be the case from’ field.

Can I issue a new fit note before the old one expires?

Yes – in certain situations it is possible that you might be asked for a fit note whilst the old one is still valid. Following your latest assessment of their fitness for work you may issue a new (overlapping) fit note if appropriate.

If I am completing a fit note using evidence from another healthcare professional, what should be the date of the fit note?

The assessment date would be the date that you considered a report from another healthcare professional, not the date of that report itself.

Can I issue a fit note with a future start date?

No. The date of statement must always be the date that you issue the fit note.

Can someone other than a doctor or GP certify a fit note?

Yes, from July 2022 nurses, occupational therapists, pharmacists, and physiotherapists can certify fit notes in addition to doctors.

My patient has 2 jobs, should I issue 2 fit notes?

No, only 1 fit note should be issued per assessment.

Your patient should show their fit note to each employer and keep hold of the original. The employer can take a copy for their own records if needed. A duplicate (clearly marked ‘duplicate’) should only be issued by you if the original has been lost.

If you use computer-generated fit notes, other staff in your practice can quickly and easily print out duplicate fit notes and thereby save you time.

What if my patient fears job loss, stigma or discrimination if I reveal their health condition (or its effect on their work functioning) on their fit note?

If you feel that revealing a particular diagnosis or limitation would harm your patient’s wellbeing or compromise their position with their employer, you can enter a less precise diagnosis on the fit note.

My patient has a personal or social problem and is asking for a fit note (for example caring for relatives). What should I do?

You can issue fit notes only to cover your patient’s own health condition. If a personal issue is causing them stress resulting in ill health, it may be appropriate to issue a fit note – this will depend on your clinical opinion.

So for example, if someone has suffered a bereavement and you assess that they are too distressed to work, it may be appropriate to write ‘distress due to bereavement’. This should only be the case if your clinical judgement is that their fitness for work has been affected. You cannot however write bereavement as a diagnosis on a fit note.

If this is not the case, you should explain to your patient that you cannot issue a fit note as they do not have a medical problem. See case study 6 for an example of this situation. Many employers offer special leave or compassionate leave in these circumstances, and your patient may be able to discuss the issue with their line manager, HR department or trade union. If they are unemployed, they should contact Jobcentre Plus.

Please see further information for support available on a range of personal or social problems that people may be struggling with.

What if my patient feels their health is being damaged by their work?

If there are parts of your patient’s job which you think may be affecting their health, you should explain these in the comments section of the fit note so that their employer is aware of them. In these cases, it may be helpful to recommend an occupational health assessment.

Remember that your assessment of your patient’s fitness for work is not linked to their particular job, so if they are still able to perform some tasks you should assess them as may be fit for work and explain what their limitations are in the comments box.

What should I do if my patient wants to change jobs due to their health condition? You are not expected to provide employment advice to your patient -Jobcentre Plus or local employment networks can help with this. In the meantime, you should use the fit note to help your patient to stay in work if appropriate.

What other sources of help are there for people with health conditions to return to or look for work?

There are a wide range of independent organisations that provide advice and support to help people stay in work or find a job. There are also further resources to help people with particular conditions or following surgical procedures – these are listed in further information.

If your patient is in work, they may be able to get help from their employer’s occupational health department, trade unions or NHS occupational health specialists. An occupational health assessment can often help. If they are out of work, Jobcentre Plus can provide support and they should discuss this with their Jobcentre Plus adviser.

Is there guidance for patients and employers on the fit note?

Yes, there are guides available for patients and employees and employers and line managers.

The fit note and employers

Is my assessment or advice binding on my patient’s employer?

No. Your assessment on whether your patient is not fit for work or may be fit for work (and any other advice in the fit note) is classed as advice. It is for employers to determine whether or not to accept your advice. They may decide to seek alternative advice and give this preference to yours. If so, they should be able to demonstrate that the quality of this alternative advice was at least comparable to yours, should a dispute between employer and employee lead to an employment tribunal.

You are not expected to get involved in such disputes between your patient and their employer. If your patient has a grievance with their employer they need to pursue this through their own arrangements, but may wish to consider organisations like ACAS. All employers have legal duties towards employees who meet the criteria of the 2010 Equality Act.

How does the fit note affect Statutory Sick Pay (SSP)?

The arrangements for SSP have not changed. If the fit note states that someone is not fit for work, or that they may be fit for work but the patient and their employer agree that they should remain off work, then they can still receive SSP.

If your patient is in doubt about their rights to SSP, they can seek advice from their trade union or an advice centre. Find detailed information about SSP.

Do I have to confirm to an employer that I have issued a fit note?

You should not provide medical information to your patient’s employer without your patient’s consent. If an employer contacts you asking if a fit note is genuine, you may choose to check the fit note serial number and confirm to the employer that you have issued it – this does not reveal any medical information, but will confirm that the fit note has been issued.

The British Medical Association has issued helpful guidelines on disclosing patient information.

The fit note and being out of work or claiming benefits

Do I use the fit note differently if my patient is claiming benefits?

No. Your assessment should still be based on your clinical judgement about the functional effects of your patient’s health condition, and you should issue a fit note only if your patient has a health condition which impacts on their general fitness for work.

How does the fit note apply to people who are out of work?

People who are out of work may ask you for a fit note for a number of reasons. There is a short guide the benefit system for GPs available. Information about benefits for patients is available, or can be found on the back of the fit note.

Further information

Guidance for patients, employers and hospital doctors

There are guides available for patients and employees and employers and line managers.

The patient guide makes clear what patients can expect from their healthcare professional – for example they should not expect healthcare professional to issue a fit note that says not fit for work if they are fit for some work.

The employers and line managers guide explains how they should use the advice in a fit note – and that if they can’t accommodate this advice, the fit note should be treated as if it stated that the patient was not fit for work.

Support for patients with personal or social problems

Fit notes can only be issued for medical problems. If your patient is dealing with a problem that is not making them ill, they should not be issued with a fit note. However there are resources available to help people with a range of other issues, which you may wish to refer patients to.

ACAS

ACAS
Telephone: 0300 1231100

Carers

NHS Social care and support guide

Carers Trust

Debt issues

Debt and money guide from Citizen’s Advice

National Debtline

Careers Advice

National Careers Service

Relationships

Relate

Benefit advice

Benefit guides

HSE guide to managing sick leave and return to work: gives advice to employers and managers about supporting people while on sickness absence and helping them to return to work.

Occupational Health Advice Service

Free professional occupational health support for individual patient cases or about occupational health in general.

England
NHS Health at Work Network

Scotland
Healthy Working Lives
Telephone: 0800 019 22 11

Wales
Healthy Working Wales
Telephone: 0800 107 0900

Details of occupational health providers

Occupational health support can be very helpful in complex cases and when work may be affecting your patient’s health. Occupational health services are sometimes provided by NHS or local authority services. To find details of providers in your area, contact:

Commercial Occupational Health Provider Association

NHS Health at Work Network – Support for Business

Supporting organisational health and well being professionals

Safe Effective Quality Occupational Health Service: list of approved occupational health providers.

Return to work support

Access to Work

Access to Work is a discretionary grant that can provide practical and financial support to people with a disability or health condition to help them start work or keep a job. The grant can contribute towards the disability related extra costs in the workplace that are beyond standard reasonable adjustments, but it does not replace an employer’s duty under the Equality Act to make reasonable adjustments. Access to Work offers personalised support and workplace assessments and can fund support such as travel to/in work, support workers, and specialist aids and equipment.

Access to Work also provides Mental Health Support Services to support people with a disability or health condition in employment with; tailored coping strategies, advice on adjustments and support for employers to enable them to better understand the challenges faced by their employees in the workplace.

Disability Employment Advisers

Disability Employment Advisers are based in Jobcentres, and work with claimants facing complex employment situations because of a disability or health condition. They can act as an advocate with prospective employers if necessary, aiming to identify work solutions that will overcome or minimise any difficulties related to an individual’s disability in the work place.

Jobcentre Plus

Jobcentre Plus provides services that support people of working age from welfare into work, and helps employers to fill their vacancies. Find your local Jobcentre.

Work Choice

Work Choice is a specialist disability employment programme that provides tailored support to help disabled people who face the most complex barriers to employment.

Guidance and support for specific conditions

Royal College of Surgeons of England – Recovering from surgery: provides practical tips and advice about getting back to work after common surgical procedures.

Royal College of Obstetricians and Gynaecologists patient leaflets: provides advice on recovery, including return to work, following gynaecological surgery

Royal College of Psychiatrists – Work and Mental Health: provides advice about returning to work after mental ill health for employees, employers, clinicians and carers.

Macmillan – Work and cancer: provides information about work and cancer for patients, carers, employers and healthcare professionals.

Royal College of Physicians – Upper limb disorders: Occupational aspects of management: Evidence-based guidance for employees.

NICE guidance on long-term sickness absence and incapacity for work

Important information about this leaflet

This is only a guide and does not cover every circumstance. We have done our best to make sure that the information is correct as of July 2022. It is possible that some of the information is oversimplified, or may become inaccurate over time, for example because of changes in the law.