Hope for OH role after all in fit note certification

A range of healthcare professionals beyond doctors were given the green light last week to begin legally certifying fit notes – with occupational health professionals conspicuous by their absence.

Now, however, new guidance published by the Department for Work and Pensions has appeared to indicate that, while OH is not explicitly listed as one of the five new professions able legally to certify fit notes, OH nurses may yet have a central role to play after all.

The guidance, ‘Getting the most out of the fit note: guidance for healthcare professionals‘, was published to coincide with changes to the regulations that came into effect last Friday (1 July) allowing registered nurses, occupational therapists, pharmacists, and physiotherapists now to certify fit notes alongside doctors.

The Royal College of Nursing has welcomed the changes, with the college’s head of nursing practice Wendy Preston arguing that, while all registered nurses will be eligible to issue fit notes once they have completed a learning programme, “in reality” it is likely only to be nurses working in general practice, occupational health and some specialist areas of secondary care who will use the new powers.

“We have been pushing and influencing for this to happen,” said Preston. “Nursing staff are often the first people patients see, particularly in primary care and especially those living with a long-term condition who may need time off to manage their condition at times.”

The guidance, nevertheless, is not entirely clear-cut. On the one hand, it emphasises that the “change is targeted at those providing relevant NHS services”. Those certifying “are not expected to have specialist knowledge of workplaces or occupational health, and you do not need to suggest possible changes to your patient’s workplace or job,” it adds.

On the other hand, the guidance states that: “Fit notes can be issued in any relevant setting where an assessment of patients’ fitness for work is made,” adding that: “It is important that the healthcare professional responsible for the episode of care is the one who issues the fit note if it is within their ability.”

The guidance also makes it clear that those with specialist OH knowledge may in practice be filling in the form. “If you do have specialist occupational health knowledge you can go into further detail about possible adaptations if you think this would help,” it states.

Moreover, within the ‘free text’ section of the form, the guidance makes the point that, for the sort of information required to fill it in, “an occupational health assessment is often helpful” with it, arguably, covering many of the elements you would expect within a standard OH assessment.

For example, it states: “The important information to include in this [free text] box is advice about the functional effects of your patient’s condition on their fitness for work. Your patient and their employer should then discuss possible adaptations and changes to accommodate your advice.

“Your advice should focus on what your patient can do at work rather than their diagnosis and symptoms. It is helpful to give advice that is as practical as possible.”

Equally, the case studies outlined within the guidance are, arguably, examples of ‘bread and butter’ occupational return-to-work assessment, rehabilitation and adaptation.

For example, one outlines supporting an employee with mild cystic fibrosis to remain in work by recommending temporary adjustments to their role to allow them to work from home during the winter months when they are more at risk from infection.

Another discusses the example of supporting a delivery driver back into work following laser eye surgery, including making a number of temporary ‘amended duties’ adjustments as their eyes heal.

As the case study concludes: “Your patient and his employer discuss your advice. Although your patient should not drive, his knowledge of the company and its operations means they decide to use him in a back office role for the two weeks. Your patient therefore retains his full pay, and keeps in the routine of working. After two weeks he goes back to work as normal without coming back to see you.”

Finally, irrespective of how this change evolves in practice on the ground, an e-learning training programme has been developed, again with input from the RCN, to support all the professions involved, including doctors, in building their knowledge and skills in relation to issuing fit notes.