The fit note isn't fit for purpose

Last Friday, the Prime Minister set out the case for overhauling the way we assess fitness for work, calling for an end to the ‘sick note culture’. He was right to do so.

In any given month, between 150,000 and 200,000 people are temporarily sick and off work – that figure has been consistent since the early 1990s. Yet what has changed in recent years is the number of people who are ‘long-term’ sick – a figure currently standing at 2.8 million – combined with a growth in those managing a number of health conditions simultaneously.

The Government has made tackling this growing issue a ‘top priority’ and the case was well made in the Express on Monday by the Health Secretary and Work and Pensions Secretary.

The Opposition clearly recognise the issue too. Sir Keir Starmer has said the prevalence of long-term sickness is “choking off growth”.

The average sickness absence per employee is currently 7.8 days – the highest level in a decade and two days more on average than in 2019.

Businesses are spending roughly a thousand pounds per employee each year on sickness absence, with the total costs (spread between the Government employers and individuals) estimated to be £150 billion per year – almost as large as the budget for the NHS.

The basis of the ‘fit note’ is that it should determine what an individual could do with the right support, but in 93.5% of cases, individuals are just signed off as ‘not fit for work’. In 40% of cases, for more than five weeks.

This isn’t fit for purpose. The current approach doesn't work for employers because they don’t receive satisfactory information to support their employees back to work. In 71% of cases, no diagnoses are provided.

The process doesn't work for GPs either who conduct over 90% of assessments. They have too little time, too infrequently discuss employment in detail with their patients or feel they have little ability to challenge or push back against those who actively seek to be ‘signed off’. Many in the profession are clearly open-minded about reform, with the Royal College of GPs saying they are "supportive of a consultation".

The process doesn’t work for the taxpayer either, with health and welfare spending becoming a growing challenge for fiscal sustainability. The Office for Budget Responsibility recently forecast that disability benefits spending will rise by 49% between 2023-24 and 2028-29.

Nor does the current approach work for the individual being assessed, because they are not receiving effective support to find or to return to work. The overwhelming majority of people want to work, but timely support is key.

The Prime Minister is therefore right to shine a light on these issues and to question whether a lack of nuance in how assessments are conducted may in fact partially feed the growth in long-term sickness and welfare dependency. It is to be welcomed that he is open to exploring the evidence for bolder reforms, such as moving much of this work outside traditional general practice.

So what do we think should be done?

In a recent report entitled "Not Fit for Purpose", Policy Exchange has recommended anyone signed-off for longer than two weeks should be referred for ‘further assessment’, such as by an occupational health professional who has more time to conduct a thorough assessment. The ability to issue repeat fit notes without ‘further assessment’ should end.

A new approach to assessing those with mental conditions in particular is needed. Not all work conditions are good for mental health, but good work is good for mental health.

There is no doubting the seriousness of many mental health conditions, but ensuring work is part of an enabling and supportive environment is key for the individual, the employer and the economy. An improved diagnostic framework and improved access to services for those genuinely in need should be part of the plan.

The Government should focus upon those currently signed off for between 1-3 months – often with mental disorders, such as anxiety and depression – where the risk of slipping into long-term sickness and long-term welfare dependency is highest.

Whilst the fit note today is uniform and analogue, it urgently needs to become a dynamic, digital tool to more effectively support those with multiple or long-term conditions or those young adults at risk of falling out of employment and education entirely, where more proactive intervention and shorter periods of absence should be recommended.

The call for evidence on fit note reform published on Friday is a welcome opportunity for the public to have its say.

Future reform should proceed with broader changes to our approach to health and work, however. Policy Exchange has also recently made the case to enhance occupational health provision – particularly for SMEs – via tax incentives.

Ultimately, big thinking is required. These matters couldn't be more important to the health of the nation and the fitness of the UK economy.

Sean Phillips is Head of Health and Social Care at Policy Exchange

Stuart Carroll is Senior Fellow at Policy Exchange (writing here solely in that capacity)

In a recent report entitled "Not Fit for Purpose", Policy Exchange has recommended anyone signed-off for longer than two weeks should be referred for ‘further assessment’, such as by an occupational health professional who has more time to conduct a thorough assessment. The ability to issue repeat fit notes without ‘further assessment’ should end.

A new approach to assessing those with mental conditions in particular is needed. Not all work conditions are good for mental health, but good work is good for mental health.

There is no doubting the seriousness of many mental health conditions, but ensuring work is part of an enabling and supportive environment is key for the individual, the employer and the economy. An improved diagnostic framework and improved access to services for those genuinely in need should be part of the plan.

The Government should focus upon those currently signed off for between 1-3 months – often with mental disorders, such as anxiety and depression – where the risk of slipping into long-term sickness and long-term welfare dependency is highest.

Whilst the fit note today is uniform and analogue, it urgently needs to become a dynamic, digital tool to more effectively support those with multiple or long-term conditions or those young adults at risk of falling out of employment and education entirely, where more proactive intervention and shorter periods of absence should be recommended.

The call for evidence on fit note reform published on Friday is a welcome opportunity for the public to have its say.

Future reform should proceed with broader changes to our approach to health and work, however. Policy Exchange has also recently made the case to enhance occupational health provision – particularly for SMEs – via tax incentives.

Ultimately, big thinking is required. These matters couldn't be more important to the health of the nation and the fitness of the UK economy.

Sean Phillips is Head of Health and Social Care at Policy Exchange

Stuart Carroll is Senior Fellow at Policy Exchange (writing here solely in that capacity)