Inside the fit note consultation
For anyone who spends time thinking about the fit note (and I probably spend far too much time thinking about it!), this week’s Sunday Times includes an article that’s worth a read.
It’s an anonymous account from a London-based GP reflecting on the conflict they experience when a patient asks for a fit note. You really get a sense of being in the consultation room with them. The highs of general practice are incredibly high, and the lows can be very low…made tougher by the sheer pace of each day. Yet, as the author emphasizes, it’s also a remarkable job, particularly because of the privilege of building relationships with patients over many years.
The GP shares several challenges associated with the fit note. There are parts of the article I take issue with, not least the recurring “sick note Britain” narrative. But it also offers rare insight into the realities of fit note conversations, something that can be hard to appreciate from outside the consulting room, as an employer, policy maker or UK taxpayer.
There’s the familiar moment when the request emerges just as the appointment should be ending: “Oh,” he said at the end of the consultation, “can I have a fit note as well?”
There’s the challenge of translating function across contexts:
“If they are capable of (unpaid work at home), then perhaps they are capable of working in a paid role as well…”
There’s the fragile nature of advocacy in these conversations: “The mood of the consultation can turn very sour… leading to a breakdown in the doctor–patient relationship.”
And there’s the very real vulnerability GPs face when patients disagree with fit note outcomes: “Complaints are made, threats are made, violence can occur.”
The author even goes on to describe being physically threatened by a patient’s partner during a fit note consultation.
The GP writing the article suggests that a neutral team of clinicians, separate from the treating clinician role, might make work-and-health conversations easier. They set out a model in which a group of healthcare professionals take on this function, a sort of multi-disciplinary, holistic service. This highlights a useful insight, especially in the context of the recently published Keep Britain Working Final Report. Access to clinical input in work-and-health discussions is essential.
Only someone with clinical expertise, and who routinely has these conversations, fully appreciates why. Work and health, unsurprisingly, involves health. Health comes with symptoms, treatments, side effects, prognoses and risks. Health and work cannot be managed end-to-end by a purely non-clinical service. And, as the author makes clear, relying solely on treating clinicians for fitness-for-work decisions has limitations.
The Keep Britain Working final report points towards a future beyond the fit note, replacing it with a neutral workplace health support function. But where the clinical input sits within this model remains unclear. And I would argue it is fundamental to its success.
