Fit note study indicates rise of mental health disorders
1 Sep 2013
Jim Hillage, Director of Research
The Statement of Fitness for Work (known as a ‘fit note’), was introduced on 6 April 2010 across England, Wales and Scotland, replacing the previous ‘sick note’. Its aim was to improve communication between individuals, doctors and employers on what a patient could do at work, thereby reducing sickness absence levels. Fit notes are issued by doctors as evidence of their advice about an individual’s fitness for work. They introduced the option to assess whether their patient ‘may be fit for work’ or is ‘not fit for work’. If a patient ‘may be fit for work’, the doctor should provide advice on return-to-work approaches to help their patient.
The Department for Work and Pensions (DWP) commissioned IES and the University of Liverpool to conduct a quantitative assessment of the fit note. To achieve this, we worked with 49 GP practices in five areas of Great Britain to collect data from fit notes for 12 consecutive months, between October 2011 and January 2013. This resulted in a database of 58,700 fit notes distributed to 25,000 patients.
Mild-to-moderate mental health disorders most common
By far the largest proportion of all fit notes in the database (35 per cent) was issued to patients for mild-to-moderate mental health disorders (M-MMDs), including depression, anxiety and stress. Specific back problems were cited on nine per cent of notes. M-MMDs were the most common diagnosis given in all fit notes across the country, accounting for over 41 per cent of fit notes issued to patients living in the most deprived areas and less than 31 per cent of fit notes issued to those in the least deprived areas.
Women were more likely than men to receive a fit note for an M-MMD, while men were more likely to be diagnosed with a back problem. Younger people were more likely than older patients to be diagnosed with an M-MMD. Fit notes issued to patients with an M-MMD living in the most deprived areas were most likely to be for depression (40 per cent of all M-MMD fit notes issued). However, fit notes issued to patients with an M-MMD in the least deprived areas were more likely to be issued for stress (34 per cent of all fit notes issued for an M-MMD). Fit notes issued for alcohol/drug addiction were more common in the most deprived areas.
Average length of a fit note episode is four weeks
Around 22 per cent of the individual fit notes issued were for a period of one week or less, 50 per cent were for between one and four weeks, 24 per cent for between one and three months and four per cent for longer than three months.
The length of time covered by the fit note varied by the diagnosis. Severe health problems, such as neoplasm and severe mental health disorders, were the most likely to lead to a fit note lasting over four weeks. Over 43 per cent of fit notes issued to patients suffering from a musculoskeletal disorder, other than a back problem, were for over four weeks. Conversely, 63 per cent of fit notes issued for a respiratory problem were for one week or less.
Patients may need more than one fit note to cover a period of sickness absence. Fit notes relating to the same incidence of ill health were grouped together into discrete episodes. Overall there were 31,000 separate episodes identified in the fit note database. Four out of five (79 per cent) of patients had only one episode of ill health during the course of the study. The median episode length was four weeks, although 18 per cent lasted over 12 weeks and four per cent lasted over 28 weeks. The diagnoses most likely to lead to a longterm sickness absence episode (i.e. of at least 12 weeks) were neoplasm, severe mental health disorder, a musculoskeletal condition other than a back problem, a circulatory problem or an M-MMD.
Males were 29 per cent more likely than females to have an episode of over 12 weeks. Episodes experienced by patients living in the most socially deprived areas were over twice as likely to be longer than 12 weeks, compared to those in the least deprived areas.
‘May be fit for work’ advice given to 12 per cent of patients
Nearly 12 per cent of all patients received at least one fit note which advised that they ‘may be fit for work’. A quarter of these patients received more than one fit note. In most cases, where the ‘may be fit for work’ box had been used, GPs also provided advice that could help the patient return to work, either by ticking one or more of the structured options on the fit note and/or writing comments in the space provided. However on seven per cent of fit notes with a ‘may be fit for work’ assessment, the GP provided no structured or free-text advice.
Mental health disorders on the increase
In seven practices in this study, comparative ‘sick note’ data had been collected in a previous study by the Mersey Primary Care R&D Consortium in 2001-02 using a similar methodology. Comparisons between the two studies need to be treated with caution as the composition of GPs and patients will have changed in the period between studies. That said, comparing the two sets of data:
- M-MMDs have increased in importance as a cause of certified sickness absence and respiratory-related sickness absence has become less prevalent.
- The proportion of sick/fit notes with durations over four weeks issued to patients has decreased. At five of the practices, the likelihood of a long-term sickness certificate being issued in the fit note evaluation was significantly reduced, compared to the sick note study, after controlling for patient and diagnostic factors.
- In three of the practices, the use of the fit note was independently associated with a reduction in sickness absence episodes of longer than 12 weeks.
 Shiels C, Hillage J, Pollard E, Gabbay M (2013), Evaluation of the Statement of Fitness for Work (fit note): quantitative survey of fit notes; Research Report 841, Department for Work and Pensions (DWP); June 2013
 Shiels C, Gabbay MB, FM Ford (2004), ‘Patient factors associated with duration of certified sickness absence and transition to longterm incapacity’, British Journal of General Practice, 54(499): 86-91