Completion of the Statement of Fitness for Work: concise guidance
Abstract
Doctors are required to issue Form Med 3 (the Statements of Fitness for Work, commonly known as the fit note) where appropriate to patients for whom they provide clinical care. Much sickness absence is attributed to mild or moderate mental ill health, musculoskeletal or cardiorespiratory conditions.1 The effects of these conditions and others can often be accommodated at work, with appropriate adjustments, adaptations or support if necessary.1 Employers have a crucial role in achieving this; however, they need advice on the functional effects of the condition to do so. Evidence shows that work can be therapeutic and help promote recovery and rehabilitation. Conversely, unemployment is generally harmful to health and can lead to increased morbidity and poorer physical and mental health, as well as poverty, health inequalities and social exclusion.1 This concise guideline has been developed to aid doctors in understanding when and how to issue a fit note to the greatest benefit for their patients.
- Department for Work and Pensions
- fit note
- Form Med 3
- return to work
- sick note
- Statement of Fitness for Work
Scope and purpose
The purpose of this article is to provide a concise guideline for doctors on the completion of the Form Med 3; the Statement of Fitness for Work (the fit note). This guideline is applicable to all doctors. However, it is particularly relevant to doctors working in settings where patients are of working age and their general practitioner (GP) is not providing the overall management of their care. This guideline may also be of use to trainee doctors, GPs and other healthcare professionals.
Background
Form Med 3; the Statement of Fitness for Work (commonly known as the fit note) is issued for statutory sick pay and social security purposes and provides medical evidence that an individual has a health condition that impacts on their fitness for work. The fit note was introduced in April 2010 replacing the previous version of the form, the sick note, which had been in use for several decades. On the fit note, a doctor can advise either that the patient is ‘not fit for work’ or that they ‘may be fit for work’. The latter is used where the doctor's assessment is that the patient's condition does not necessarily mean that they cannot return to work; however, they may not be able to complete all of their normal duties or hours, or they may need some support to help them undertake their normal duties. (There is no longer the option to advise that a patient is fully fit for work; in such cases doctors should simply not issue a fit note.)
Completion of fit notes is not the sole role of GPs. All doctors are required to issue fit notes where appropriate to patients for whom they provide clinical care. Examples of settings in which this might be appropriate include:
an outpatient clinic (where the GP does not retain responsibility for ongoing clinical care) such as a fracture clinic
on discharge from hospital after a stay as an inpatient
after treatment in accident and emergency.
This guideline is aimed at doctors in secondary care who may be less accustomed to completing fit notes, and may have less understanding of their duty in this respect and when it is appropriate for them to issue one.
This guideline refers specifically to the fit note–Form Med 3. Doctors working in an inpatient setting may also be aware of, or issue the Department for Work and Pensions (DWP) Form Med 10 which is used to record a period of stay as an inpatient. The Med 10 does not include any medical opinion/advice and simply records the time spent in hospital. The Med 10, unlike the fit note, is not restricted to doctors and can be issued by other hospital staff.
Why is it important for doctors to complete fit notes?
Neglecting to complete fit notes can result in unnecessary GP consultations and difficulty for patients in obtaining sick pay or benefits. Importantly, it can also mean patients and their employers do not receive the necessary advice concerning fitness for work which could delay or prevent the patient returning to work.
There is also strong evidence that long periods out of work are associated with poor mental and physical health, increased use of health services and health inequalities.1 In most cases an individual does not need to be 100% fit to return to work, and this is supported by the many thousands of people with long-term health conditions who are in work. It is important that work is considered an indication of success in the outcomes of treatment of patients of working age and is included as an important outcome in clinical research.
The evidence reviews for the National Institute for Health and Clinical Excellence (NICE) guidance Managing long-term sickness absence and incapacity for work found that workplace modifications could speed up return to work, particularly for those off sick with musculoskeletal problems.2
When completing a fit note, doctors should always consider if the patient could return to work with some support from their employer. The advice provided on a fit note can be crucial in determining if, when and how a patient returns to work. When advising that the patient ‘may be fit for work’, the doctor should always provide some advice in the comments box on the form outlining the functional effects of the condition and/or how a return to work could be facilitated. Tick boxes setting out four common methods of supporting patients to return to work are included on the form to aid this process (see ‘Tools for doctors’ opposite). The advice in the comments box should describe the limitation(s) that the person may have and should not be too prescriptive about the solution(s). For example, it would be more appropriate to advise that a person with lower back pain ‘cannot sit for long periods of time’ rather than ‘should be provided with a better chair’ or that a person with travel-related anxiety might benefit from ‘avoiding travel in peak hours’ rather than ‘should work between 10 am and 4 pm’.
A fit note can be written on the basis of a report from another registered healthcare professional, such as a nurse, physiotherapist or occupational therapist (as well as other doctors). Other healthcare professionals can provide a useful contribution to the provision of fit notes and return to work advice. Patients with more complex needs may be referred to specialist vocational rehabilitation services or local community rehabilitation teams. Details of this are beyond the scope of this article. Specific guidance is available for example in the National Service Framework for Long-term Conditions3 and guidance from the British Society for Rehabilitation Medicine (BSRM)4 and the Royal College of Physicians London (RCP).5 While originally written for people with neurological conditions, these guidelines have general applicability across a wide range of chronic disabling conditions.
Advising on fitness for work and the completion of fit notes is not currently included in the majority of medical undergraduate and postgraduate training. Completing a fit note and advising on fitness for work does not require specialist knowledge of workplaces or occupational medicine; however, it does require doctors to consider the functional impact of an individual's condition and treatment. All doctors should be able to provide simple fitness for work advice and support to aid their patient's recovery and to help them stay in, or return to, work. It is then up to the employer to determine if, and how, these recommendations can be implemented, based on their detailed knowledge of the workplace and the individual's job.
Comprehensive guidance on the completion of the fit note is available from DWP including specific guidance for doctors working in a hospital setting.6 In addition, several royal colleges have produced evidence- and consensus-based guidelines covering best practice for advising on fitness for work in general and for specific conditions (see Box 1).7–9 E-learning designed specifically for doctors in secondary care is available from Healthy Working UK, an online resource on health and work developed by the Royal College of General Practitioners, the Faculty of Occupational Medicine and the Society of Occupational Medicine.10
Where work may be a contributor to the patient's condition or the health and work issues are complex, doctors may use the fit note to recommend that an occupational health assessment be considered.
Limitations of the guideline
This guideline is based on government-issued guidance (developed in partnership with the Royal College of General Practitioners and the British Medical Association) on the completion of the fit note. The evidence base for the relationship between work and health is set out in Waddell and Burton.1
Footnotes
In association with the Health and Work Development Unit A collaboration between the Royal College of Physicians and the Faculty of Occupational Medicine
- © 2012 Royal College of Physicians
References
- ↵
- Waddell G,
- Burton AK
- ↵ National Institute for Health and Clinical Excellence. Managing long-term sickness absence and incapacity for work 2009London: NICEwww.guidance.nice.org.uk/PH19/Guidance/doc/English
- ↵ Department of Health. National Service Framework for Long-term Conditions 2005London: DHwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4106042
- ↵ British Society of Rehabilitation Medicine. Vocational assessment and rehabilitation for people with long-term neurological conditions: recommendations for best practice 2010London: BSRMhttp://www.bsrm.co.uk/Publications/VR4LTnCv45fl.pdf
- ↵ Royal College of Physicians. Vocational assessment and rehabilitation after acquired brain injury: inter-agency guidelines 2004London: RCP
- ↵ Department for Work and Pensions. DWP Health and Work Guidance: Statement of Fitness for Work–Med 3www.dwp.gov.uk/healthcare-professional/guidance (accessed August 2011)
- ↵ Royal College of Surgeons of England. Get well soonwww.rcseng.ac.uk/patient_information/get-well-soon (accessed August 2011)
- Royal College of Obstetricians and Gynaecologists. Recovering wellwww.rcog.org.uk/recovering-well2011 (accessed August 2011)
- ↵ Royal College of Physicians/NHS Plus. Upper limb disorders. Occupational aspects of management. A national guideline 2009London: RCPwww.nhsplus.nhs.uk/providers/images/library/files/guidelines/rev_upper_limb_disorder_guideline_webnavigable.pdf
- ↵ Royal College of General PractitionersFaculty of Occupational Medicine and the Society of Occupational Medicine. Healthy working UKwww.healthyworkinguk.co.uk (accessed August 2011)
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- Turner-Stokes L,
- Harding R,
- Sergeant J,
- Lupton C,
- McPherson K
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