Health and Wellbeing: Are 'fitnotes' working?

In April, fit notes were introduced to help prevent sickness turning into long-term absence. But there are doubts about whether the system will work.

For years now, Britain has been getting more and more sick. This decade the number of people on long-term incapacity benefit has risen by more than half a million, to 2.4 million. Of these, 1.23 million have not worked for more than five years and evidence shows there is a strong link between those initially being 'signed off' work and then eventually becoming long-term sick - about 350,000 annually.

The response to this has been the introduction of the fit note or, more precisely, a 'Statement of Fitness for Work'. Doctors can still sign people off sick, but now they also have the option to state that staff 'may be fit for work taking account of the following advice'. Business groups have overwhelmingly supported the move, but in the two months since its launch controversy surrounding the scheme has shown no sign of abating. Doctors feel they are being pressurised into confirming people are well enough to work when they should actually be taking time off. HRDs, meanwhile, are caught in the middle - between taking their duty-of-care responsibilities seriously, and being mindful that absence costs UK plc more than £100 billion per year, according to Dame Carol Black's 2008 Working for a Healthier Tomorrow report. So what is the nature of the conflict and what can be done to assuage it?

The GP view

While GP advice, which applies to employees who are off sick for seven days or more, is not binding, it does focus on the duties employees can perform rather than what they cannot. Although bosses are also faced with new responsibilities to implement the adjustments doctors recommend, such as a phased return to work or flexible working, it is GPs that are entering totally new territory.

A major concern is that they are being asked to make judgments they are not necessarily qualified to make. "We've repeatedly said GPs have no direct knowledge of people's workplaces and are not occupational health physicians," says Richard Vautrey, who is deputy chair of the British Medical Association's General Practitioners Committee. "We would much rather employers invest in or create new occupational health facilities. Unless we monitor the situation, there is a risk patients' visits could become a sort of formal occupational health assessment."

While it is too early to assess the impact fit notes will have, last year a trial of the system among 543 GPs found that the proportion of patients with back pain or depression who had received a 'not fit for work' judgment fell from 88% to 58%. More (38%) patients were assessed as fit for work when applying the new system, than not. GPs said only 12% of the same patients would have been deemed able to work had fit notes not been applied. While government and business groups may feel vindicated by this, for HRDs it confusingly signals GPs either routinely used to sign people off too quickly, or that they really are under more pressure to judge people as being well for work, when normally they would have said they are not. Legal firms are already warning a new breed of claims could arise - from stressed or ill employees that have been forced back to work too early by the fit note system.

All the evidence suggests it is pressure to say staff are fit for some form of work that is dominant - and against GPs' better judgment. A survey by HR's sister magazine, GP, found 15% of doctors would prefer staff are fully recovered from any illness they have rather than let them go back to work prematurely. Vautrey thinks sick employees could be passed from pillar to post: "If organisations request their staff need a further assessment by their occupational health team before they can return, there is risk of some confusion for patients," he says.

Phillip Hodson, a fellow of The British Association for Counselling and Psychotherapy, is worried about how the services needed to back the scheme will be funded. "There are no doubt plenty of people registered unfit to work, who would like to work," he says. "But a lot of support services will be needed to create the culture of being able to work and we're a debt-burdened country at the moment."

The employer view

While the medical profession has genuine concerns over taking responsibility for assessing workers' health, there are worrying signs the scheme has yet to gain whole-hearted buy-in from employers.

On the eve of fit notes being introduced, a study published by workforce management systems specialist Kronos found 35% of employers in both the private and public sector were unaware of them. Of those that did know, 64% of HR, operations and general managers have received no guidance about what to do when an employee produces one from their GP and over a third (38%) believe the note will create more problems than it solves.

An early intervention prevention study conducted at the same time by Aviva UK Health shows only 5% of employers think fit notes will actually reduce absence rates and get employees back to work sooner. Furthermore one in 10 of the 500 employers questioned believed they would be hard to administer, with 68% having little or no knowledge of the change and how it would work for them.

"We are concerned by the apparent lack of awareness of fit notes among employers and their workforce," says Hugh Laing, chief medical officer for Aviva UK health and a practising GP.

He adds: "While fit notes will encourage employers to act more responsibly towards employee rehabilitation and perhaps more importantly help prevent ill-health in the first place, the initiative doesn't give them the tools to do so."

The major worry focuses on the role of line managers. "What do line managers know about wellbeing, health, reasonable adjustments and the differences between what is required by disability and discrimination legislation and a fit note?" asks Kevin Friery, clinical director of employee assistance programmes provider Right Corecare. "Similarly, with at least 40% of GP consultations now conducted with patients that have emotional and psychological problems, managers need to know how to direct the conversations they have with employees about their health. They also need to receive guidance from their own organisation on how much leeway they have to actually implement any recommended adjustments."

But perhaps this fear comes from companies that do not have robust health, wellbeing and absence management systems in place. "I fully expect the introduction of fit notes to be a pain-free exercise," says Ann Pickering, HR director of O2 UK, optimistically. "Far from creating an additional resource or administration headache, they will complement our existing processes, including our occupational health service." This includes assistance to support managers in dealing with the day-to-day wellbeing of people through to information for employees about steps they can take towards an early return to work.

Likewise, while anticipating that fit notes will result in some reduction in absence rates, Niki Coppard, director of HR operations at Lloydspharmacy, stresses her organisation has always encouraged individuals to consider the option of returning to work with adjustments. "The fit notes should help to provide a more structured discussion and should not be more time-consuming," she says. "The crux of the matter is communication and engagement of managers, through briefing guidance to ensure they understand how to hold their discussions."

But Sara Edwards, director of HR Worldwide at Orient-Express, is more cautious. "Initially I don't think fit notes will make a great deal of difference, but over time I expect they will," she says. "The positive side is that if an employee returns to work in some capacity rather than not all, then this may be a good trade-off to make." She does, however, stress HR's role in helping GPs understand what tasks an employee usually performs and in delivering what they may recommend. "By ensuring line managers and the wider team are trained appropriately, fully understand the process and, most crucially, are communicated with regularly, you can help combat potential misunderstandings."

The middle ground?

GPs and HRDs clearly need to talk. A survey by HR magazine finds just 37% of HR practitioners think fit notes will reduce absence rates, and there is concern that returning to work early will only create further absence in the longer term.

Shaw Trust, the national charity that supports disadvantaged people in preparing for work, advises employers to ensure they have a framework in which all parties are able to be open and honest. Lucie Ellis, the Trust's HR co-ordinator, says: "Where the value is placed on more than just pay, work can be a positive contributor to general health and wellbeing. Employees do not only need to get back to work, but sustain that return. A frank discussion on the options for achieving this is imperative."

Organisations that have systems to record the information contained within fit notes are likely to find the change more straightforward. "If employers do not have a system to store this information, then fit notes will prove challenging to administer," warns Aaron Ross, chief executive of absence management services provider FirstCare.

Without proper communications between staff, HRDs and GPs, one type of provider - the EAP/health cash plan provider - could be an intermediary caught in the firing line. One that HR magazine spoke to predicted a doubling of calls from worried staff - something it feared could divert its resources away from dealing with other genuinely ill and worried employees. A survey by Group Risk Development (GRiD) last month showed family and home issues (which cash plan providers typically deal with), are the top cause for workplace absence, at 18%. These findings add weight to just how complex the root causes of workplace absence can be.

For organisations seeking further guidance on the new fit note there are resources to help. The Department of Work and Pensions has free information for employers on its website, while training is also available through Acas. Meanwhile, the Institution of Occupational Safety and Health (IOSH) provides free guides on rehabilitation and return-to-work issues on its website.

"Good work is good for health and wellbeing and, among other things, this means work that's safe, supportive and accommodates people's individual needs," says IOSH policy and technical director Richard Jones. "There's also evidence positive perceptions about work are linked to higher productivity, profitability and staff retention. We are hopeful that once employers understand what's expected and what help is available and begin to see the benefits to their employees and organisation, doctors and employers alike will embrace fit notes."