What the Fit Note Is... and What the Fit Note Is Not
I have been writing about the fit note for four years now. As I engage with more stakeholders, my understanding of its role and limitations continues to evolve.
We must acknowledge that the fit note cannot be expected to fill the entire gap in the occupational healthcare landscape.
Acknowledging this specifically is important.
Otherwise, fit notes will be relied upon to fill the gap. This is is inappropriate and unlikely to be effective.
AND/ OR
The gap in the occupational healthcare landscape will simply continue to go unaddressed.
Even if fully optimised, the fit note alone cannot meet the broader needs of supporting work and health outcomes in the UK. Here’s why
In complex cases, fit notes issued by treating clinicians cannot deliver the nuanced work and health advice that occupational health input can provide. This is due to several inherent limitations within the treating clinician context:
1. The treating clinician’s position on the work and health agenda
The incentives for an accurate work and health assessment often align with clinical priorities — supporting patients to return to work where appropriate or to take sickness absence when they are unfit to work.
However, in a time-pressured consultation, the work and health agenda is rarely the primary focus. Treating clinicians must prioritise diagnosis, treatment, and symptom management — leaving little space to explore work adaptations in depth.
Even if time and patient expectations were optimised (i.e. in a world with longer GP consultation times, where the ‘sick note’ narrative does not prevail), the role of work and health within a treating clinician's remit will always differ from that of occupational health professionals, whose core focus is on the intersection of work and health.
2. Skills in occupational health
The fit note was designed so that it could be used without requiring specialist occupational health expertise.
While this has made the fit note more accessible, it comes with limitations in its precision as a tool in practice.
In more complex cases, clinicians without occupational health training cannot reasonably be expected to deliver the detailed work and health advice required to support a safe and sustainable return to work using a fit note.
3. Knowledge of the patient’s workplace
Treating clinicians only have one side of the picture — the patient’s medical needs — without access to more detailed information about the workplace, job demands, or available adjustments.
Even the best occupational history can only get the consultation so far in a treating clinician context.
This distance from the workplace limits a treating clinician’s ability to offer tailored, pragmatic advice on fitness to work.
The fit note’s role in the bigger picture
I believe there is still more to be done to get the most out of the fit note. For most working people, it remains the only formal route to work and health advice. What’s more, it features relatively early in an individual’s sickness absence journey and this comes with opportunity to implement early support.
However, I believe sole focus on improving the fit note, or treating clinician led work and health interventions more generally, will only yield marginal gains. The fit note, by design, is a broad-brush tool that cannot fully address the complexity of the UK’s work and health challenges. Treating clinicians cannot be expected to take on the work and health agenda in its full remit.
To truly close the gap in the occupational healthcare landscape, we need investment in wider access to occupational health services. Nothing will replace expert, personalised, third party, workplace-focused advice.
