Another issue with the fit note...
This month, I was been invited to speak at two GP training programmes about making the most of the fit note.
This is always something I am interested in doing since it has been something I have struggled with in practice. In fact, it was one of the catalysts for me upskilling in occupational health.
The directors at both programmes had particular asks for me to cover:
What happens when patients are not happy with fit note outcomes?
Where does this leave the healthcare professional?
Are they vulnerable to complaints, litigation and professional consequences?
These questions are relevant in how we practice medicine more generally. Safeguards for patients mean consequences for healthcare professionals delivering care that is inadequate. This is completely appropriate.
However, people often describe medicine becoming increasingly ‘defensive’ around risk. Mostly, this refers to concerns around excessive clinical activity such as over investigation but it can also refer to practicing medicine that is patient led rather than person centred.
Guru of general practice and the art of consulting Dr Roger Neighbour says in his book Consulting in a Nutshell
“Patient-centredness incorporates two elements. The first is the importance of understanding illness as experienced from the patient’s point of view - something about which they have thoughts and feelings, worries and expectations. The second is that the patient is an active participant in how the consultation is conducted, and especially in how management choices and decisions are made.”
Many analogies draw parallels between aviation and medicine. I find that these analogies don’t always check out (more on this in another blog at some point). However, Dr Roger Neighbour goes on to explain patient-centredness in a relatable way:
“If I board a plane to fly to Tokyo, I want control of the aircraft to be pilot-centred, not passenger-centred. But I want the destination to be passenger-centred, not pilot-centred. The ideal flight would be passenger-selected but pilot-flown. Be like that pilot. Get your patient safely to where they need to be, using all the knowledge, skills, and experience at your command. That’s what being patient-centred means’.
When it comes to completing fit notes, person centredness is key. This does not mean certifying people fit, not fit or may be fit for work if the healthcare professional does not think they are. The tenants of person centred medicine involve aligning the patient’s and doctor’s agendas, and using shared decision making to come to a plan. When done well, there should be unity on the consultation outcome. However, there is very limited guidance to lean on where this is not the case, when it comes to using fit notes.
For the majority of healthcare professionals working in general practice who are not occupational health trained, this puts up another barrier to effective use of the fit note. This adds another dimension to the recent House of Lords economic affairs committee report, calling for an overhaul of the fit note.
As I was looking into this, I came across interesting learning useful to share, helpful in navigating this dilemma while also revealing limitations in the status quo.
Government advice is that healthcare professionals should certify the note based on fitness to work generally, rather than with any specific role in mind. While this may be appropriate in the GP context (limited time, limited OH expertise, limited knowledge of any one patient’s workplace) it really isn’t a practical vantage point. Depending on the health condition, the nature of the work really does have a bearing on fitness to work.
Government advice suggests that the finer details of amended duties are figured out in the workplace. Where employers are competent in this it can work well. Where they are not it can be challenging and even counter productive or risky for both employer and employee. Employers cannot be expected to be literate in medicine. The government says “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 judgement”. This said, healthcare professionals may feel in a vulnerable position leaving the finer details open in cases that need to be handled with care. This may explain some decisions to certify fit notes as not fit to work at all.
For people who are self employed, fit notes may still be useful as a means to discussing workplace adjustments or as a route to statutory sick pay e.g. if employed as director of own limited company, or as evidence for employment and support allowance social security payments. These individuals won’t have a workplace sounding board to figure out the details of ‘maybe fit for work’ locally. Does this mean they are at a disadvantage when trying to navigate a change in health at work?
The indemnity provider MDDUS signposts to GMC guidance that “doctors must be "honest and trustworthy when writing reports, and completing or signing forms, reports and other documents" and must ensure that any such documents are not "false or misleading". It also states that doctors should use their own judgement when applying these principles in their everyday practice and that they must be able to explain and justify any decision made or action taken.” In summary, fit notes must be authorised ethically and honestly.
The indemnity provider MDDUS signposts to GMC guidance around fitness for a broader range of activities such as for jury duty or a court appearance, saying that “(doctors must ensure that) care is taken to ensure appropriate consent is given and the patient is happy with the letter’s content before it is sent. Such letters can provide factual medical information but the issue of providing an opinion is more nuanced. You should consider whether you are in a position to provide such an opinion, or if an independent specialist may be better placed.” Summarised, this means that clinicians should recognise when to ‘stay in their lane’ when asked to provide an opinion on fitness for tasks they may not have appropriate expertise to certify for.
It’s useful for all stakeholders to understand the parameters of the guidance out there. But looking at the guidance also reveals more shortfalls in what the fit note can achieve.
