Efforts to keep people in employment after an illness or injury have been affected by a lack of occupational health awareness, investment and support. Becky Spencer reports.

When the Statement of Fitness for Work or 'fit note' was introduced in April 2010, it was seen as a radical move away from the ‘sick note’ system, which had been in force across England, Wales and Scotland in some form since 1922.

The aim was to switch the focus away from what patients can’t do and to instead consider what they can do, and in doing so help people to remain in work or get back to work as quickly as possible.

Fast forward 14 years, and it is clear that it hasn’t quite worked out like that. Dame Carol Black, who recommended the change to an electronic fit note in her groundbreaking 2008 report Review of the Health of Britain's Working Age Population recently said: “I have to come to the very sad conclusion that we didn’t succeed”. She highlighted that too many people were still being consigned to an “inexorable journey into worklessness”.

So, what’s gone wrong?

At the heart of the current fit note system is the idea that good work is good for health.  It is well known that the longer someone is out of work, the more difficult it is for them to return. Which is why the fit note system was designed to encourage healthcare professionals to explore with patients and employers the options for a prompt return to work, including any workplace adjustments which would facilitate this. In most cases, these conversations are not happening, mostly due to time restraints and a lack of specific work and health expertise in primary care.

When a fit note is issued, a healthcare professional – nurses, occupational therapists, pharmacists and physiotherapists can issue fit notes as well as GPs – can recommend that a patient is either ‘not fit for work’ or ‘may be fit for work’ followed by recommendations that will allow this. These include: a phased return; altered hours; amended duties; and adaptions to the workplace. 

However, the data shows the ‘may be fit for work’ option is rarely chosen. Between April 2023 and March 2024, nearly 11 million fit notes were issued in England alone. Only 6.5 per cent of these recommended that the patient ‘may be fit for work’. The vast majority (over 10 million) said the patient was not fit for any work at all during the period covered by the fit note.

Around 60 per cent of fit notes issued in 2023/24 were for less than 28 days. The remaining 40 per cent (4.2 million) were for between five and twelve weeks, and it is the patients behind these longer-term fit notes that the fit note system should be helping most. So why isn’t it?

Lack of resource

Firstly, the NHS is overwhelmed and under resourced. Knowing this, when issuing a fit note, healthcare professionals are left with very limited choices as to how to get an employee back to work quickly. Take mental ill health and musculoskeletal/joint disorders, for example. Apart from pregnancy-related sickness, these are the two main reasons fit notes are issued. However, many employees with these illnesses cannot return to work quickly because they are stuck on NHS waiting lists for treatment they desperately need for their recovery, such as physiotherapy or mental health assessment or counselling.

Secondly, there is a massive black hole in the occupational health support available from employers. With NHS waiting lists as long as they are, this OH void is keeping staff with the most common health conditions (mental ill health and musculoskeletal disorders) out of the workplace for longer than both employers and employees would want.

Recent government research found only 28 per cent of employers provide OH services to their staff, meaning just 45 per cent of workers have access to some form of OH support. Unsurprisingly, small businesses (particularly micro businesses) are less likely to provide OH support than larger firms.
The amount and type of OH support provided varies enormously.  The 2023 Simply Health/ CIPD Health and Wellbeing at Work survey, which canvassed the views of over 600 firms employing millions of people, found that while most  (82 per cent) offered staff access to an online/telephone employee assistance programme, only two-thirds said they offered some  form of counselling and a third said they offered some access to physical therapy.

Only a quarter of companies said they offer all employees health plans that provide access to independent services like GP appointments, physiotherapy, chiropractors, or counselling. Access to an occupational health specialist was also limited, with just 42 per cent of organisations (mainly in the public sector) using them to manage stress/mental health issues.

The reasons why employers don’t provide suitable OH provision when they have so much to gain from providing it are complex and have proved difficult for various governments to fix. Cost is the main barrier but other issues such as a lack of understanding about what OH involves and the value it can bring to a business also play a role.

Raising awareness of OH

This year’s Occupational Health Awareness Week (23-29 September) aims to address this lack of awareness. The Society of Occupational Medicine, which organises the week, will be publishing a range of resources for employers explaining what OH is and the value it provides to workplace health. A short film introducing small firms to OH is already available here.

In April, the previous Government set up an Occupational Health Taskforce which was expected to publish advice for firms of all sizes on the minimum level of occupational health support needed  to keep employees in work, as well as to make recommendations on how to improve OH take-up by employers.  Since the General Election, there has been no word on when, or if, the OH Taskforce will report back, however the new Government has said it will publish a White Paper on its plans to ‘Get Britain Working’ this autumn. These plans are expected to include reforms to the fit note system, a process that was started by the previous administration.

Fit note reforms currently being considered include:

• Establishing a new triage service to support people seeking a fit note into a pathway that best suits their individual health and employment needs.
• Assessments with healthcare professionals or work and health advisers who have received specific work and health training and have the time available to take into consideration a wider set of factors that affect someone’s ability to work.  
• The ability for healthcare professionals to refer people on to more intensive work and health support, with support for employers to access expert work and health support through Occupational Health services, where appropriate.

For any of these proposals to be successfully taken forward, significant investment is needed. But with the Government telling us there is a £22billion hole in the country’s finances, there are doubts that the amount of money needed will be forthcoming.  Yet without this investment, any changes to the fit note system will be like putting a sticking plaster on a broken leg – totally ineffective.