GP fit notes: who can issue them and when?

As the list of healthcare professionals who can legally issue a GP fit note has recently changed, here is an overview of what you need to know about them

CREDIT: This is an edited version of an article that originally appeared on CQC

From 1 July 2022 nurses, occupational therapists, pharmacists and physiotherapists have been able to legally certify and issue fit notes; previously only GPs or hospital doctors could do this.

This change will make it easier for people to get this advice certified by the most relevant healthcare professional and enable them to have better conversations about their work and health with their employers; it will also ease pressure on the workload of GPs.

Key changes to fit notes are:

• They can only be issued following an assessment of a person’s fitness for work, so cannot be issued on request, or through over-the-counter services.
• They do not need to be signed in ink. This enables eligible healthcare professionals to certify fit notes digitally and means people can receive their fit note through digital channels (where GP IT systems support this).
• When first conducting fit note certification, the health care professionals (HCP) who are legally able to certify fit notes should complete the Health Education England elfh training modules on fit note certification, and have a period of structured mentorship and support.

The HCP should be involved with the assessment, diagnosis or care planning of the patient the work and health conversation relates to, or be able to form an assessment based on a written report by another HCP.

Guidance for patients from the Department for Work and Pensions (DWP) explains that:

• People can self-certify sickness for up to the first seven days of the illness.
• From the eighth day they need to submit medical evidence to pursue a claim.
• They should tell Universal Credit about a health condition preventing them from working.

The fit note focuses on what patients are able to do in relation to their work. GPs, nurses, occupational therapists, pharmacists and physiotherapists are able to consider the ‘may be fit’ option which brings together clinical aspects of illness and how it affects function and ability to work.

Information from NHS England states that patients do not always need to see a GP in person to get a fit note. It depends on:

• why they are off work sick;
• whether a GP needs to assess the patient face-to-face;
• whether the patient has been in hospital.

The role of practice staff

All GPs, nurses, occupational therapists, pharmacists and physiotherapists can provide simple fitness for work advice; this can help patients return to work and aid their recovery. It is then up to a patient and their employer to discuss the advice and consider possible changes.

There is a general consensus that it is good practice for GPs and other healthcare professionals to:

• 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;
• help return to work through shared decision-making;
• enable patients to effectively communicate with their employers.

Evidence to support regular work

Evidence that being in the right work is good for people’s health is now well established; being out of work can increase long-term health risks. Most people with long-term health conditions do work. If patients are likely to be absent from work, the advice from a GP in the fit note can have a major influence on their future wellbeing, particularly if people are absent from work for a long time.

GPs, nurses, occupational therapists, pharmacists and physiotherapists should carefully consider whether to tell a patient that they are not fit for any type of work at all; this increases their longer-term health risks.

Guidance for GP practices

Guidance from the DWP, Fit note: Guidance for GPs sets out how GPs, nurses, occupational therapists, pharmacists and physiotherapists should:

• assess a patient’s general fitness for work rather than making it job-specific;
• consider whether a patient could do some form of work – if this is not possible, only then advise that they are not fit for work.

Facts about fit notes

Guidance suggests when it may be appropriate to use the ‘may be fit for work’ box on a fit note, and offers extra advice to give to patients. Issuing staff can use the free text boxes to give advice on what the patient can or can’t do. 

Staff need to consider this in line with occupational health advice from the patient’s employer. Practice staff should encourage patients to discuss with, and agree a return to work programme, with their line managers. The text in the fit note should reflect this.

GPs, nurses, occupational therapists, pharmacists and physiotherapists 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. 

Many people seeking a medical certificate are declared completely unfit. This is wholly warranted when the patient’s condition precludes any form of work during expected recovery time or indefinitely.

All GP practices with GPSoC systems can access the computer-generated fit note template; this saves time and can be sent electronically. The system pre-populates many of the details and stores them on the patient record. The DWP will accept fit notes that are printed, signed, scanned and emailed to patients. When signing and sending fit notes electronically, it’s important to consider:

• confidentiality;
• information governance.

When filling in a fit note doctors need to consider a patient’s functional capacity – as well as considering the patient’s capacity to return to their own job, they also need to look at returning to work in general. This approach opens up ways to return to work that a patient may not have otherwise considered.