When completing a fit note, the doctor is providing advice to the patient, who may then share it with his or her employer and/or use it as evidence of eligibility for sick pay or social security benefits.
If the patient’s health problem precludes all work and is not expected to resolve within the immediately foreseeable future, the Department for Work and Pensions asks that this assessment be recorded and a date specified for review that reflects the anticipated clinical course (up to three months ahead in the first six months of incapacity, but thereafter the review period can be longer or even indefinite, if clinically appropriate). There is no point in early review if the incapacity for work will not improve materially in the short term. Nor is it mandatory to see the patient before completing the note. When a telephone consultation or reports in the patient’s clinical record provide the necessary information, the doctor’s assessment can be based on these.
If the patient will be incapable of work for a short period (such as after surgery) but should then be able to return directly to his or her normal job, the doctor can indicate that the patient will be unfit for work over the relevant period but that no further assessment is needed thereafter. As a default, the patient would then return to work when the certificate expired. Setting the date for restarting work in the middle rather than at the beginning of a working week may make the transition less daunting for the patient.
When the doctor believes that the patient is incapable of his or her normal job but might be fit for modified work, the form offers an option to record this and to tick boxes recommending consideration of (a)
a phased return to work, (b)
altered hours, (c)
amended duties, or (d)
workplace adaptation. These four options are not mutually exclusive, and, if appropriate, more than one can be recommended. It is not essential to use them, but if the patient is recorded as possibly fit for modified work then some form of explanatory comment is required (box 3
Box 3. Examples of modifications that may help a patient to return to work
Phased return to work
The patient could restart with reduced working hours and build up gradually to normal levels. Working fewer hours each day is usually preferable to fewer days each week
Consider the time of work as well as the number of hours a day—for example, a patient recovering from depression may find early starts especially difficult
Changes in the organisation of work might help: an anxious patient with reduced confidence may benefit from working in a team rather than alone; a secretary with rheumatoid arthritis who found typing difficult could be allocated alternative administrative duties if colleagues were available to share in the work
Changes in job content might help: a patient with back pain may need to avoid prolonged sitting to reduce discomfort; a patient with anxiety or depression may need to avoid tight deadlines; a patient with newly diagnosed insulin dependent diabetes may need to avoid foreign travel temporarily
Changes to seating or other aspects of a work station may be necessary to improve comfort in a patient with back pain
A patient with an arthritic left ankle may need to switch to a car with automatic gears
In providing explanatory comments, doctors should be careful to remain within the limits of their knowledge and competence. Nonetheless, it may often be possible and worth while to offer simple advice to the employer. Such advice is best framed in terms of function—in particular, whether there are activities at work that the patient would find difficult or impossible (such as lifting weights heavier than 10 kg, working to tight deadlines, travelling long distances by car). In addition, it may help to highlight aspects of the job that the employer could consider modifying. However, advice that is too prescriptive may be counterproductive. The employer has more detailed knowledge of the workplace than the doctor and is better placed to identify specific modifications that are feasible. Box 4
gives examples of the types of advice that might be given.
Box 4. Examples of advice for an employer about a patient’s function and possible job modifications
“He should avoid lifting weights greater than 10 kg. Might it be possible for him to transfer temporarily to work in customer service?”
“She should avoid prolonged sitting without breaks. Review of her work station might be useful. She will need time off twice a week to attend physiotherapy”
“She cannot currently drive a car. So that she can use public transport it would help if she could start and finish work a little later than normal”
“He should avoid kneeling and squatting”
“She could manage work that does not involve handling customer complaints”
In some cases, especially where the employer has an occupational health service, the certifying doctor may include a recommendation for specialised occupational health assessment. This might be helpful, for example, in cases where the patient’s job could have contributed to the patient’s health problem.
Employers are not obliged to follow doctors’ recommendations. In some cases, job modifications may not be practical, in which case the patient will be treated as if he or she is unfit for any form of work. However, systematic review suggests that where modifications are feasible they can accelerate return to work.25