What is needed to move the dial on fit notes?
What is needed to move the dial on fit notes?
I caught up with Professor Kim Burton to discuss routes forward on fit note reform.
The Autumn Statement pledged reform to the fit note process to bring in support earlier on in the sickness absence journey. With a growing labour force gap and around 2.5 million people economically inactive due to long term ill health and disability in the UK, policy change that supports people living with ill health back into work and encourages retention of those in work has a bearing on the prospects of the UK economy. The fit note is a sensible place to start because of its position as a gateway to longer term sickness absence early in the work and health journey. However, the fit note, as currently used, is failing to deliver its original promise: innovative, perhaps radical, reforms are needed.
Any reform must unite all stakeholders in facilitating change to how the fit note is used. The government has alluded to early intervention on work and health including the roll out of trials delivering early joined up support, similar to research currently being undertaken. A key element of these pilot programmes, along with the Employment and Health Discussion for people seeking benefits, is the development of a formal agreed plan for returning to work or maintaining work ability. Currently, though, it is the fit note that remains the communication route between the key players – worker; healthcare; workplace. In order to be effective, fit note reform must meet the (sometimes conflicting) agenda of the three different user groups.
Workers
Workers are going to be open to ‘may be fit for work’ advice and appreciate their health issue can be accommodated at work, they need to be supported in reaching an understanding that a fit note is not a binary ‘sick note’. This is challenging, because data tells us that more 90% of the time, fit notes are signed as ‘not fit’ - in effect being used as a binary ‘sick note’. This translates to a lost opportunity to begin the conversation about the positive relationship between work and health. Public communications and media reporting around work and health echoes this narrative…‘sick note Britain’. Reframing the dialogue around fitness for work in mainstream media and communications is essential to managing patient expectations and successful shared decision making. A conversation around when somebody ‘may be fit for work’ needs to land in place of empowerment, rather than be perceived as punitive.
Healthcare professionals
It might surprise patients, workers and employers to know that doctors and allied healthcare professionals authorising fit notes may not have any work and health specific training and find it difficult to address the topic. Nuanced decision making around how to use the ‘may be fit for work’ section to support patients to keep working where possible is not formulaic or guideline driven and can be challenging. Squeezing a thorough fit note conversation at the end of a busy 10 minute consultation centred around the underlying health condition the patient presented with can be logistically impossible. In order to make better use of the fit notes they are authorising, healthcare professionals need adequate resources, including time, and training, to develop deeper understanding of how many common health problems can, in principle, be accommodated across different workplaces.
Employers
Employers receiving fit notes need to be empowered in using them as a springboard to keep the person working during a period of ill health where appropriate. This means an emphasis on work ability, and exploring, with the worker, the options for adaptations and amended duties to support them at work. A fit note authorised with ‘may be fit for work’ options is only as useful as an employer makes it. In many organisations there is limited expertise on how to implement next steps, with nowhere to turn for advice, meaning there is little opportunity to negotiate accommodation. Employers need to feel confident and safe having conversations about work and health for fit note reform to be effective.
Moving forward
Fit note reform cannot be unilateral. For change to be effective all three stakeholder groups need to be on this journey. A public health campaign with reach to people who are in work and off work, as well as healthcare professionals and people in the workplace, especially line managers and people in HR leadership positions on the relationship between work and health and the principles of accommodation is much needed to counter decades worth of negative messaging.
There is, then, an opportunity to move from negative perceptions to where work and health are seen as complementary not conflicting, thus fostering the notion of ‘working while recovering’ – moving the emphasis from a purely medical perspective to one that empowers the worker and the workplace to agree an individualised plan to accommodate this person, with this health problem, in this job.