Are fit notes making the nation sicker?

Individuals in the UK with health conditions may be entitled to two types of benefits: incapacity benefits (for those whose condition prevents them from working) and disability benefits (to help with living costs arising from the disability). The cost of health related benefits for people of working age is now £48 billion this year.1 This is predicted to increase to £63 billion by 2030.1 If spending on health related benefits continues to grow as forecast, the UK will likely become one of the highest spenders on health related benefits among comparable countries. The latest figures show there are currently 2.83 million people who are “economically inactive,” primarily due to long term sickness. This reached a near-record high in the period of December 2023 to February 2024.2 Given the right incentives and support from GPs, this group could go back to work.

Obtaining a fit note is the first step in the process of someone stopping work and becoming economically inactive. Recently published data show that almost 11 million fit notes were issued in 2024, with nearly 94% of those signed in primary care as “not fit for work.”3

NHS Digital data also show that 9.5 million fit notes were issued in 2018-19 compared with 11 million in June 2023 and June 2024—a 15.8% increase compared with pre-pandemic levels.3 Some of this increase will be due to covid related long term sickness when a full evaluation of patients was not possible and the longer term effects of long covid. There has also been a substantial rise in consultation numbers in general practice after covid-19. This now stands at 30 million GP consultations a month, the equivalent of half the population being seen in general practice in England every month.4

The pressure on GPs’ time could indicate a more widespread problem in general practice, with too many GPs under pressure to issue fit notes rather than support and properly evaluate the request. People receiving sickness related benefits can expect up to £5000 more a year than people receiving jobseekers’ allowance, and they do not have to attend a job centre or adhere to other conditions. There is, therefore, a huge pressure from patients on GPs to sign these notes because it can make a material difference to their income.

The problem may also be related to the 7.57 million people (September 2024) on the NHS waiting list for appointments and procedures. Many of the increasing numbers of people signed off as too sick to work are experiencing genuine illness or living in pain. But we also know that fit notes are issued when the patient is simply signed off rather than having a full evaluation, which requires assessing whether the individual can do some form of work rather than just signing them off as “Not fit for work.”5

We believe that there is a lack of understanding by GPs and patients of the vital role of employment in the health and wellbeing of patients and their families and the “deconditioning effect” of being unemployed. Described mainly in older people, deconditioning in younger age groups because of physical and mental inactivity has been little studied.6 Many GPs will witness a decline in patients’ health as a result of being signed off sick from work. It is also increasingly difficult to support patients back into work after an extended period out of work. In the Bromley By Bow Health Centre a few years ago, we ran a project trying to get patients back into work after six months on incapacity benefit. The leader of the project told me how unsuccessful the project was and that the only solution lay in GPs not issuing a fit note in the beginning. The project found that the deconditioning after six months of not working was almost irreversible.

So, what is the solution? GPs need to understand the devastating impact of unemployment on patients’ health and wellbeing. They also need to be freed up to prioritise time spent in consultations where there is a request for a fit note and recognise the importance of an accurate assessment. The 4000 social prescribers in general practice need to be trained to help patients return to work, and their numbers need to be expanded so that any request for a fit note is managed by them and the clinicians. The Department of Work and Pensions (DWP) needs to assess every patient after three months of sick leave, and GPs should be able to refer patients for a second opinion by the DWP.

Fit notes need to be clear about the time when a patient is incapable of any work (such as after surgery) and then what is possible in the rehabilitation period. There needs to be a cultural shift about mental health so that a return to work is recognised as part of treatment except for severe mental health problems. GPs need to recognise the importance of this along with more time and resourcing. Some NHS mental health trusts have social prescribers and job advisers, but many do not. Some 15% of adults in England are taking antidepressants, with little evidence of clinical effectiveness, particularly in mild to moderate depression, nor a clear correlation with a reduction in suicide.7 The total number of antidepressants prescribed in England increased by 36% between 2016 and 2023. There was a concomitant 23% increase in the number of patients receiving antidepressants in this period.8 This possible overprescription and overtreatment will be addressed only with clinical education and the provision of alternate social and psychological prescriptions.

General practice has a critical role in improving the quality of the fit note process, improving the health and wellbeing of patients and ensuring we have a healthy workforce. GPs need to be part of the solution, not the problem.