How do GPs complete fit note comments?

Demographic variation in fit note receipt and long-term conditions in south London

Objectives

Introduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.

Methods

Data were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.

Results

In a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.

Conclusions

For the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

Systematic review of fit note use for workers in the UK

OBJECTIVES

The fit note, introduced in England, Wales and Scotland in 2010, was designed to change radically the sickness certification process from advising individuals on their inability to work to advising them on what they could do if work could be adapted. Our review aimed to evaluate the following: (1) Is the 'maybe fit' for work option being selected for patients? (2) Are work solutions being recommended? (3) Has the fit note increased return to work? (4) Has the fit note reduced the length of sickness absence? We considered the way in which outcomes vary according to patient demographics including type of health problem.

METHODS

Studies were identified by a systematic search. We included all studies of any design conducted in the UK with working age adults, aged 16 or over, from 1 April 2010 to 1 Nov 2017. Risk of bias was assessed using a modified Newcastle-Ottawa Scale.

RESULTS

Thirteen papers representing seven studies met inclusion criteria. In the largest study, 'maybe fit' for work was recommended in 6.5% of fit notes delivered by general practitioners (GP; n=361 801) between April 2016 and March 2017. 'Maybe fit' recommendations were made in 8.5%-10% of fit notes received by primary care patients in employment, and in 10%-32% of patients seen by GPs trained in the Diploma in Occupational Medicine. 'Maybe fit' was recommended more for women, those with higher socioeconomic status, and for physical, as opposed to psychiatric disorders. The majority of fit notes with the 'maybe fit' option selected included work solutions. There was inconclusive evidence to suggest that the introduction of the fit note has reduced sickness absence among patients in employment.

CONCLUSIONS

Fit notes represent a major shift in public policy. Our review suggests that they have been incompletely researched and not implemented as intended.

Stakeholder perspectives on the new sickness certificate in Victoria: results from a mixed-methods qualitative study

Objective The aim of this study was to present the views of four stakeholder groups, namely general practitioners (GP), employers (EMP), injured workers (IW) and compensation agents (CA), about the content and usability of the draft of the new Victorian sickness certificate. Methods A cross-sectional mixed-methods qualitative study was conducted in GP clinics and community settings in Melbourne, Australia. Interviews were conducted with GPs, EMPs and IWs and one focus group discussion was completed with CAs (n = 29). Data were collected between October and December 2013. Thematic analysis was performed. Results All stakeholders viewed the new draft certificate as an improvement on the old one. GPs saw the certificate as a form of communication, whereas EMPs and CAs saw it as a therapeutic device. GPs continued to certify based on incapacity and provided little information about what IWs could do on return to work. All groups said that assessments for mental health needed more clarity and specificity. GPs, EMPs and CAs also said that the new certificates must be electronically available and integrated into existing medical software to streamline uptake. Conclusions To ensure appropriate use of the new certificate, stakeholders must share a common understanding about its purpose and the certificate must be incorporated into existing medical software. Content on mental health assessment, an area of continued difficulty, needs additional refinement. The new certificate replaced the old certificate in March 2015; after it has been established in clinical practice, an impact evaluation should be completed to determine whether GPs are certifying capacity and earlier return to work. What is known about the topic? When it comes to sickness certification, GPs tend to focus on what injured patients cannot do, rather than what they can do. The new sickness certificate aims to change GP behaviour by focusing the certificate more on capacity (i.e. what the injured patient can do). What does this paper add? Four stakeholder groups agreed that the content and usability of the new certificate has improved. However, they agreed that the assessment of mental health capacity needs further specificity. Dissonances also remain between the stakeholders on the purpose of the certificate. What are the implications for practitioners? Appropriate use of the new certificate requires a common understanding about the purpose of the certificate, training on its appropriate use, incorporation into existing medical software and clarity on mental health assessment.

Irish GP attitudes towards sickness certification and the 'fit note'

BACKGROUND

Sickness certification poses significant challenges to most general practitioners (GPs). As an alternative form of certification, in 2010, the UK implemented the 'fit note', which focuses on returning to work after illness. It has been well received in the UK but little is known of non-UK GP attitudes towards the fit note.

AIMS

To evaluate the challenges Irish GPs experience with the current sickness certification system and their attitudes towards the fit note.

METHODS

A questionnaire assessing attitudes, practices and preferences regarding the fit note was developed, piloted and posted to a representative sample of Irish GPs selected by systematic sampling. Descriptive statistics, chi-square tests and binary logistic regression were used to analyse the results.

RESULTS

Of 305 GPs surveyed, 64% (196) completed the survey. Ninety per cent (177) of responders reported a lack of available rehabilitation services for patients on sick leave and 66% (124) reported adverse effects of sickness certification on therapeutic relationships with patients. Those who indicated a preference for introducing the fit note (53%; 104) were significantly more likely to endorse both an excessive focus on disability [odds ratio (OR) = 3.16] and lack of GP training (OR = 2.04) in the sickness certification process.

CONCLUSIONS

Difficulties associated with sickness certification are apparent at GP-patient, GP-employer and GP-health service levels. Addressing these will require intervention at each of these levels and may be facilitated by challenging the assumption that illness equates to disability.

Return-to-work outcomes and usefulness of actual fit notes received by employers

BACKGROUND

GPs can use the fit note to advise that a patient 'may be fit' or is 'not fit' for work. Previous employer-based research on the fit note is largely qualitative and based on general perceptions and past experience. Knowledge of the return-to-work outcomes and usefulness of actual fit notes is needed to strengthen the evidence-base and inform practice.

OBJECTIVE

To investigate the return-to-work outcomes of fit notes issued to employed patients, and their employers' opinions as to the usefulness of each note.

METHODS

Participating organizations collecting fit notes were asked to rate the outcome and usefulness of each fit note via postal questionnaires. Quantitative data were analysed descriptively; qualitative data were analysed using thematic content analysis.

RESULTS

Five hundred and sixteen questionnaires were posted, with a 97% return rate (n=498). More than 80% of employees (n=44) returned to work after the expiry date of a 'may be fit' note compared with 43% (n=167) of those issued with a 'not fit' note. Fit notes were considered more useful if they provided information on the condition and its effect on the employee's ability to work, if they stated whether or not the employee needed reassessment and if clear advice regarding return-to-work had been provided.

CONCLUSIONS

'May be fit' notes are useful in helping employees return to work. However, this option is infrequently used, and the completion and content of many fit notes does not meet employers' needs. These factors need to be urgently addressed if the fit note is to reach its full potential.

General practitioners and sickness certification for injury in Australia

Background

Strong evidence supports an early return to work after injury as a way to improve recovery. In Australia, General Practitioners (GPs) see about 96 % of injured workers, making them the main gatekeepers to workers’ entitlements. Most people with compensable injuries in Australia are certified as “unfit to work” by their GP, with a minority of patients certified for modified work duties. The reasons for this apparent dissonance between evidence and practice remain unexplored. Little is known about the factors that influence GP sickness certification behaviour in Australia. The aim of this study is to describe the factors influencing Australian GPs certification practice through qualitative interviews with four key stakeholders.

Methods

From September to December 2012, 93 semi-structured interviews were undertaken in Melbourne, Australia. Participants included GPs, injured workers, employers and compensation agents. Data were thematically analysed.

Results

Five themes describing factors influencing GP certification were identified: 1. Divergent stakeholder views about the GP’s role in facilitating return to work; 2. Communication between the four stakeholder groups; 3. Conflict between the stakeholder groups; 4. Allegations of GPs and injured workers misusing the compensation system and 5. The layout and content of the sickness certificate itself.

Conclusion

By exploring GP certification practice from the perspectives of four key stakeholders, this study suggests that certification is an administrative and clinical task underpinned by a host of social and systemic factors. The findings highlight opportunities such as practice guideline development and improvements to the sickness certificate itself that may be targeted to improve GP sickness certification behaviour and return to work outcomes in an Australian context.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0307-9) contains supplementary material, which is available to authorized users.

Completion of fit notes by GPs: a mixed methods study

AIMS

The aim of this study was to investigate the completion of fit notes by UK general practitioners (GPs). A series of actual fit notes issued to employed patients were examined, and their GPs' reflections and experiences of fit note completion explored.

METHODS

A mixed-methods design was used. Data were collected from copies of 94 fit notes issued to employed patients by 11 GPs, and from 86 questionnaires completed by these GPs reflecting on the fit notes they had issued. Face-to-face interviews were then conducted with each GP.

RESULTS

Fit note completion is not meeting expectations for a number of reasons. These include the following: limited knowledge and awareness of the guidance in fit note completion; problems with the fit note format; lack of mandatory training in completing fit notes; lack of incentive to change practice; incomplete implementation of the electronic fit note; GPs' lack of confidence in, and doubts about the appropriateness of performing this role.

CONCLUSION

If UK GPs are to continue their contractual responsibility for completing fit notes, further consideration of their education and training needs is urgently required. Weaknesses in the design and format of the fit note and the availability of the electronic version also need to be addressed.

The influence of prior training on GPs’ attitudes to sickness absence certification post-fit note

Aim

To investigate the attitudes to health and work of general practitioners (GPs) with training in occupational medicine (OM) compared with non-OM trained GPs, since the introduction of the fit note.

Background

Changes to the UK sickness certification system since 2010 and the introduction of the fit note required GPs to change their focus to what patients can do, rather than what they cannot do in relation to work. In an effort to reduce the UK sickness absence burden, GPs completion of the fit note should help to keep people in work, or assist patients to return to work as quickly as possible after a period of absence.

Methods

Questionnaire data were collected via the 7th National General Practitioner Worklife Survey.

Findings

Results indicate that responses from GPs who had undertaken training in OM, and GPs having received some form of work and health training in the 12-month period before the study were associated with significantly more positive attitudes to patients’ returning to work and to the fit note. This study reveals evidence of a difference between trained and non-trained GPs in their attitude to the fit note, and to work and health generally. Further work investigating the effect of specific training in OM on the management and recognition of ill-health by GPs is recommended.

Recording occupation in general practice--a second cycle audit

BACKGROUND

An audit of working age patients' records in two Cornish general practices in 2012 found infrequent and inconsistent recording of patients' occupations. A concurrent survey of general practitioners (GPs) in Cornwall found that a majority of them believed it was important to do so.

AIMS

To review occupation recording in the same practices a year later and to audit a third practice, following the introduction of the electronic fit note. To repeat the survey of attitudes to recording occupation in GPs in Cornwall.

METHODS

We manually checked 300 randomly selected patient records in Practice A and electronically searched all records of working age patients (aged 16-65 years) in Practices B and C for recorded occupation. We sent an electronic survey of attitudes to recording occupation to 202 GPs in Cornwall.

RESULTS

Recording of occupation increased from 17 to 30% of records (χ(2) = 15, P < 0.001) in Practice A and from 12 to 14% (χ(2) = 16.5, P < 0.001) in Practice B. In Practice C, 1% of records had occupation recorded and coded. The proportion of GPs in Cornwall who said that it is important to records patients' occupation increased from 70 to 90% (Fisher's exact statistic 0.01, P < 0.05).

CONCLUSIONS

Recording of patients' occupation increased in both practices from 2012 to 2013, but remains infrequent and inconsistent and the very low levels in a third practice not previously audited is of concern.

Employers' views on the fit note

BACKGROUND

The fit note replaced the sick note in 2010. The statement of fitness for work (fit note) is expected to benefit the British economy by helping more people stay in work and prevent long-term sickness absence. Understanding and responding to employers' views on the fit note is key, in order for this goal to be achieved.

AIMS

To explore employers' views on the fit note.

METHODS

A qualitative study was undertaken and face-to-face interviews were conducted with participants representing employers from a variety of industries.

RESULTS

There were 21 participants who were mainly human resources officers and line managers. Employers welcomed the introduction of the fit note and felt that it was an improvement on the sick note. The majority of employers felt the fit note had the potential to promote an earlier return to work, if used properly. The main problems reported were the completion of the fit notes and quality of advice received from general practitioners. Employers felt that the most helpful advice came from fit notes with information on the functional effects of the medical condition. Some employers found return to work decisions problematic.

CONCLUSIONS

The fit note has the potential to promote an earlier return to work. In order for the fit note to achieve its aim, further understanding of the difficulties employers are having when making return to work decisions is important, in order to develop guidance to enable them to provide the practical support employees need to return to work sooner.