Welfare reforms and fitting the fit note in: Takeaways from the RCGP Conference
The recently passed bill on welfare reforms remains controversial. My concerns include:
Focussing on welfare is a relatively late touchpoint in someone’s work and health journey. In many cases, people transition onto welfare after at least 100 days of sickness absence. It is likely to be higher yield to focus on upstream interventions.
The quality of support in any consultation on work and health, including when it is part of a welfare offering, needs to improve to include:
Access to subject matter expertise on risk, function and psychosocial factors that are relevant to assessments and support around fitness for work.
Continuity of care and scope for a responsive service that can offer reassessment as conditions change, and use time and longitudinal follow up to deliver results.
Advanced consulting skills pitched at a conversation of two parts. Determining what someone is ‘not fit’ to do should not be the sole endpoint of a work and health consultation. Data gathering, analysis and shared decision making should also determine what they are fit to do. This can often be the starting point to undertake take some economic activity.
Last month, I ran a workshop on fit notes at the Royal College of General Practitioners (RCGP) with senior colleagues Dr Shriti Pattani OBE and Dr Kabir Varghese.
In a room full of GPs some with decades of experience, others working across a range of primary care settings, the session evolved into something much richer than I anticipated! What began as a practical discussion about using the fit note soon opened up into a wider conversation about the pressures, complexities, and opportunities when it comes to discussing work and health in general practice.
These insights are relevant to share in the context of the recent controversy surrounding welfare reforms in the UK. For the majority of the population, fit notes are the earliest available route to clinical work and health support. The timing is ideal for a high yield conversation. Fit notes could hold the key to ensuring people with health issues affecting their ability to work get the support they need to get back to some sort of economic activity ASAP. In an ideal world, fit notes would be the infrastructure that avoids the situation deteriorating into long term economic inactivity due to ill health, ultimately requiring welfare support.
But the fit note is difficult to leverage to its full potential. I have seen this first hand from my own practice, as well as from the data. Being in a room full of GPs working across settings added a lot more depth to the situation.
Here are some of the insights that came out of the conversation:
• Patients who have been on welfare for years being re-engaged on health and work via fit note consultations, prompted by DWP requests. This is challenging to make the best of in 10 minutes (or less when it is a second issue).
• Time pressure in general practice limiting clinicians’ ability to complete the “may be fit for work” section safely, sometimes right down to the time cost of a few extra clicks.
• Non-clinical staff being delegated to issue “not fit” certificates to preserve clinician time for more acute or undifferentiated presentations.
• ‘Duty’ doctors defaulting to “not fit for work” as a way to manage high-volume days and decision making, seeing 40+ patients with limited continuity and minimal context.
• Clinician knowledge gaps around how the fit note fits alongside DWP processes and employer-led support, which limits its use as a signposting tool.
• Clinician concern about patients’ ability to self-advocate in situations at the work- health interface, especially when shaped by social determinants of health.
• Difficulty for both clinicians and patients to keep pace with the changing welfare landscape and new policy directions that do not always translate clearly into practice.
• Challenges with patient engagement in local work and health services where these exist, due to fears these will be punitive, as well as health issues being a block to engagement.
Despite these challenges, GPs shared examples of good practice, often in difficult circumstances. Some spoke of finding creative ways to preserve continuity of care for patients whose work and health are intertwined. Others described using advanced consulting skills, such as motivational interviewing, to help patients explore return-to-work options. And some highlighted the importance of stepping back to call for wider system change.
One of the most powerful moments came when GP Dr Sandra Danso Bamfo challenged the DWP’s line that clinicians should provide advice about an individual’s “fitness for work in general” that is “not job-specific”. She pointed out that this undermines the nuance needed to complete the “may be fit for work” section in a way that is truly helpful for patients and employers alike. It suggests that all doctors and allied health care professionals are being asked to do is determine if a patient is fit or not fit for any type of work in general. This devalues the ‘may be fit for work’ section, that the fit note was introduced to offer.
Yet, is a 10 minute GP consultation an appropriate context for detailed and job specific advice? And if not, the gap between reality and the DWP guidance directly links to challenges all stakeholders have in getting more out of the fit note, which may even relate to welfare influx down the line.
Determining fitness for work is a process that at minimum involves
Data gathering (across both work and health)
An understanding of contextual psychosocial factors
Clinical risk assessment
Shared decision making
I would argue that fitness for work advice must have some job specificity to be useful in making progress at the work/ health interface.
Lara’s take
The session was a timely reminder: fit notes can be a powerful tool, but only if we acknowledge their limitations, understand the wider system they sit within, and are given the time, support, and space to use them meaningfully. Drawing a line at general and non job specific advice may make it seem more excusable to fit the fit note in as a second issue in a ten minute GP consultation, but maybe it cuts out the majority of the utility. In a policy landscape where a lot of attention is on the welfare system, I think more focus needs to be upstream on early work and health consultations, and figuring out where the fit note fits in is part of this.
