Has OH been overlooked (again) in fit note changes?

The government has outlined plans to extend fit note certification to a range of other health professionals. The move is potentially good news for occupational health yet, as Nic Paton reports, the worry is that, yet again, ministers have failed to recognise the valuable contribution OH could make.

From next month (1 July), nurses, occupational therapists, pharmacists, and physiotherapists will all be able legally to certify fit notes – something that at present only doctors can do – under plans outlined earlier this month by the Department for Work and Pensions and Department of Health and Social Care.

The change has been billed by the government as being “the most significant since the fit note’s inception in 2010” and could potentially present an opportunity for occupational health practitioners.

SOM, the Society of Occupational Medicine, has expressed the hope that the change will lead to a new conversation around work and health, one where the impact of one on the other is better recognised and articulated.

As SOM chief executive Nick Pahl has put it: “The fit note acts as an important backstop to occupational health in GP practices, ensuring contact with a healthcare professional relatively early in a period of sickness absence.

“However, the fit note is rarely used to its full potential, with fit notes generally focusing on the ‘not fit’ for work option, rather than the ‘maybe for work’ section. Over a third of fit notes are also often issued for five weeks or longer, by which time around 20% of people will never return to work.”

Assessment of fitness to work

So, what exactly is the government proposing?

The extension of fit note certification follows changes made in April this year that allowed for fit notes to be certified and issued digitally, which made the process more efficient for employees, employers and GPs. Patients can also now receive their fit note via digital channels, where their GP practice IT systems support this.

Under the latest change, regulations were laid before Parliament on 10 June to allow more healthcare professionals to certify fit notes. These professions, the government outlined, will include nurses, occupational therapists, pharmacists, and physiotherapists.

Fit notes will still only be able to be issued following an assessment of a person’s fitness for work – something commonly carried out by OH of course – and it will not be that fit notes can be issued on demand or over the counter.

The government has also argued the change “will be delivered in general practice and hospital settings”.

This means the direct role or input of OH practitioners – essentially whether OH nurses will be able to write and certify fit notes themselves – remains somewhat unclear.

Minister for disabled people, health and work Chloe Smith has emphasised the move is about helping to reduce pressure on hard-pressed primary care, while both simplifying processes and bureaucracy.

“The extension of fit note certification is fantastic news for patients, making it easier for them to get the support and advice they need from the right place, ensuring where possible that they are able to remain in work,” she said.

“These latest fit note changes recognise the valuable role other professions play in helping manage people’s health, and I hope this will also help reduce unnecessary bureaucracy for doctors and general practice more widely,” she added.

The move has also broadly been welcomed by doctors and allied health professionals. British Medical Association GP committee deputy chair in England, Dr Kieran Sharrock, said: “This announcement is a positive step and we hope that it will go some way to both improving the process for people who need confirmation that they are too unwell to work, and free-up GPs time to care for patients who need their expertise.

“The BMA has been clear for many years that it may not always be necessary or appropriate for a GP to issue a fit note, especially when a patient has seen a different member of the practice team for their condition, such as a nurse or physiotherapist.

“At a time when the entire NHS is under pressure, reducing unnecessary administration and bureaucracy, while taking a more flexible and pragmatic approach to patient services is absolutely vital,” he added.

Karen Middleton, chief executive of The Chartered Society of Physiotherapy, argued physiotherapists “are ideally placed to have conversations about health and work with patients.”

She added: “The longer someone is off work the less likely they are to return, so physiotherapy expertise at the start of an absence can be crucial for ensuring their rehabilitation is effective and they can get back in a timely manner.

“So this announcement is good news for patients, with the added benefit being that they don’t need to make a separate appointment to get signed off by a GP,” Middleton said.

And Karin Orman, director of practice and innovation at The Royal College of Occupational Therapists, said: “Workers and employers are crying out for more help to support people with health problems to stay in work where they are able to do so. These new changes mean occupational therapists are directly able to provide that advice.”

Wider reform agenda

At one level, these changes to certification can be seen as part of a continuum, feeding into and complementing the government’s wider reform agenda for workplace health as outlined in its response to the Health is everyone’s business consultation.

This, to recap, outlined plans for the development of a subsidy model to encourage employers to invest in occupational health provision, new non-statutory guidance on supporting disabled people and people with long-term health conditions to remain in work, the possibility of a new Centre for Work and Health Research, the expansion of fit note certification (as has now happened), and work on how to expand OH’s workforce capacity.

However, as SOM recently highlighted, we’re now a year on from that response and, beyond certification, very little further has changed in practice.

The worry, therefore, is that the role, expertise and potential of OH to make a difference – once again – gets overlooked in what may yet become a significant change.

The fact that occupational therapists and physiotherapists were included within the government announcement, yet not occupational health, is a worry.

Equally, the insistence that this new certification approach will only take place in primary or secondary care rather than having the flexibility to, say, happen within a workplace setting, does not bode well.

This is despite the fact that OH practitioners are, arguably, among those best placed to be making these sorts of certification decisions and, crucially, will understand both the nuances of fit note certification and the particular circumstances of a worker’s employment.

As one practitioner on the occupational health practitioners’ Facebook group put it following the announcement: “Look forward to hearing how we can influence this initiative. We in OH, especially in-house, are best placed to assess ability to attend work; we know the risks and hazards and also what can be accommodated.”

Equally, GPs themselves have made it clear that fit note certification is something where OH could, and maybe should, be taking a lead. In May, for example, a conference of GP local medical committees described needing to issue a fit note within the first four weeks of illness as ‘a huge drain on GP resources’ and called for an independent occupational health service to be set up to do this work instead.

Nevertheless, SOM, for one, is putting a positive face on things. It has argued, for example, that changing certification in this way offers an opportunity to kickstart wider awareness-raising around the role, impact and effectiveness of OH as an intervention.

To that end, it is calling for the certification change to lead to more comprehensive training in use of the fit note, including ensuring essentials in occupational health is covered within the undergraduate and postgraduate curricula.

“Tailored occupational health advice should also be made available to patients who receive the fit note – with better use of the ‘maybe fit’ for work section (for example, suggesting a physiotherapist advises on return to work for back pain),” it has argued.

“SOM would also like to see fit note certification acting as a potential referral point to an occupational health professional,” the society has added.

That in itself would of course be a hugely positive outcome for OH. However, the changes to fit note certification, while welcome, may unfortunately also have illustrated that putting occupational health at the forefront of the workplace health and wellbeing conversation, let along front and centre of the government’s reform agenda, remains a job to do.