The ability of GPs to issue fit notes and deal with work and health issues is ‘questionable’, according to a Government-commissioned review.
Sir Charlie Mayfield, a businessman and former chairman of John Lewis, is currently leading an independent review of what more the Government and employers need to do to tackle ‘economic inactivity due to ill-health and disability’.
In this first ‘discovery’ phase of the review, Sir Charlie noted that general practice is the ‘first port of call’ for those in periods of ill-health, and that current NHS data show that GP waiting times ‘are generally not a major issue’.
‘However, the ability of general practice to play this first-line role is much more questionable,’ he claimed.
The report pointed out issues with general practice staff not being qualified in occupational health, their lack of knowledge about a patient’s ‘workplace dynamics’, and the lack of time to ‘get to the bottom’ of any workplace barriers.
It claimed that these potential competency issues resulted in 93% of fit notes issued by general practice staff stating ‘not fit for work’, citing NHS Digital data covering the first six months of 2024/25.
This same dataset showed a slight reduction in the proportion of ‘not fit for work’ notes issued by general practice, down from 94% in 2022/23.
Sir Charlie’s review claimed there is a ‘disparity’ between the level of detail employers ‘might expect’ from fit notes, and the level of detail healthcare professionals offer.
‘While signing someone off as being unfit for (all) work may be appropriate in some cases, it may be less so in others, especially where retaining a connection with the workplace is beneficial to the individual and makes a return to work more likely,’ he added.
This review, named ‘Keep Britain Working’, follows a white paper of the same name published in November, which unveiled plans to place ‘work and health coaches’ in GP practices to get more people back to work.
The Government also recently announced a raft of welfare reforms in a bid to save over £5bn in the coming years.
These plans did not explicitly mention fit note reform, but the Government promised to ensure the changes did not place additional pressure on general practice by increasing ‘demand for medical evidence and requests for fit notes’.
Under the previous Government, ‘Work Well’ pilots began in 15 ICB areas to test removing fit note responsibility from GPs.
Former Prime minister Rishi Sunak also said last year that GPs may not longer be responsible for fit notes as they struggle to be ‘objective’ and sign them ‘by default’.
The current Government has not laid out its stance on fit note reform, but work and pensions secretary Liz Kendall affirmed support last week for the Work Well pilots, which are ‘trialling new approaches like GPs referring people to employment advisors, instead of signing them off sick’.
Sir Charlie’s independent review on work and health will make its final recommendations to the Government in the autumn.
The Covid era suspension of the requirement for Gp blessing for all workplace troubles, ill health, illness tested benefits etc was transformative. We only saw ill people for a while.
file under “no s***, Sherlock”
The Endless Sick Note Cycle: Why GPs Should No Longer Be Responsible for Fit Notes
Very early on (more than a couple of decades ago…) I observed how there is something uniquely British about the sick note. It has become more than just a piece of paper; it is a system, a ritual, a lifeline, and in some cases, a trap. It is also a burden that GPs were never meant to carry, and yet, here we are—caught in an endless loop where doctors, patients, and employers all play their part in an arrangement that serves no one well.
Every day, GPs sit across from patients who ask—sometimes plead—for a fit note. The reasons vary: physical pain, mental distress, work-related stress, or simply the inertia of long-term absence. And every day, GPs must make a decision based on limited evidence, no workplace insight, and under the silent but ever-present threat of complaint.
There is a deep psychodynamic tension in this interaction. The GP is meant to be an ally, someone who listens, who understands. But when that same GP is also tasked with deciding whether a patient can work, the nature of the relationship shifts. Compassion is forced to make room for gatekeeping, and advocacy is compromised by regulation. The patient sees the doctor as their only means of securing time off, while the doctor—aware of the limited time, the lack of workplace context, and the risks of refusal—finds it easier to sign the note than to challenge the request.
This is not an exaggeration. NHS Digital data shows that 93% of fit notes issued in the first half of 2024/25 stated “not fit for work.” The numbers are staggering but not surprising. The system is not built to assess fitness for work objectively—it is built to avoid confrontation. The GP’s clinical judgment is often overridden by the fear of complaints, the pressure to keep consultations moving, and the knowledge that refusing a fit note might create more problems than it solves.
But here is the uncomfortable truth: there is no robust evidence that staying off work improves health outcomes. In fact, for many conditions—particularly those related to mental health—the evidence suggests the opposite. Prolonged absence from work often leads to worsening depression, anxiety, and a loss of purpose and routine. Studies by Waddell and Burton (2006) emphasize that, for most people, work is beneficial for health, and long-term sickness absence can exacerbate mental health conditions. The OECD (2012) has also highlighted that staying in work, where possible, is an essential factor in preventing mental health deterioration, while prolonged work absence is linked to poorer outcomes.
And yet, we have created a system where entire generations of families remain on long-term sick leave, often cycling through different diagnoses but never truly returning to employment. In some cases, it starts with a legitimate condition but evolves into something else – a learned dependence on the system, a deepening of social isolation, a severance from the world of work that becomes harder to reverse with each passing year. As evidenced in the 2018 Health and Work Report by the UK Government, economic inactivity due to ill-health has become a major contributor to the rising burden on social services and the NHS.
GPs were never trained to be occupational health specialists. They do not know the specifics of a patient’s job, they do not understand the workplace dynamics, and they certainly do not have the time to engage in a meaningful discussion about work adaptations. Yet, they are expected to make decisions that affect not just the patient, but also their employer, their colleagues, and the wider economy.
The Faculty of Occupational Medicine (FOM) has long advocated for fit notes to be handled by occupational health specialists rather than GPs, acknowledging that workplace context is vital for a fair and accurate assessment. The Royal College of General Practitioners (RCGP) itself has suggested that GPs should not act as gatekeepers for sick notes due to their lack of expertise in work-related assessments.
The solution is clear: GPs should no longer be responsible for issuing fit notes. Instead, fit notes should be handled by:
1. Independent occupational health professionals—experts who can assess both medical and workplace factors.
2. A separate GP service that does not involve the patient’s usual doctor, ensuring objectivity and removing the psychodynamic conflict.
This shift would:
• Improve objectivity, reducing the pressure on GPs to default to ‘not fit for work’ notes.
• Enhance decision-making, as specialists in occupational health would provide a more informed assessment.
• Reduce unnecessary work absence, particularly in mental health cases where prolonged absence may be harmful rather than helpful.
The economic implications of this issue are staggering. The UK has one of the highest rates of economic inactivity due to ill-health in Europe, and in some communities, there are multi-generational patterns of long-term sick leave and welfare dependence. The 2018 Health and Work Report noted that worklessness, especially when caused by long-term sickness absence, is a significant drain on the economy, leading to greater reliance on disability benefits and increased pressures on public health services.
Remaining in work—even with adjustments—is often the key to maintaining overall well-being, as studies consistently show that individuals who stay in work during illness have better long-term recovery outcomes compared to those who remain off work. This is especially crucial in the case of mental health conditions, where engagement with meaningful activity can have a restorative effect.
GPs should be healers, not gatekeepers. It is time to take fit notes out of their hands and put them where they belong: in the hands of those trained to assess work capacity fairly and without bias.
We must stop enabling the cycle of dependency that has trapped generations of families in long-term sickness absence. This is not about being harsh or unfeeling; it is about ensuring that decisions about work and health are made fairly, accurately, and with the right expertise. It is about breaking the cycle of sick-note dependency that has left too many people out of work—not because they are incapable, but because the system made it too easy to stay away.
As the evidence overwhelmingly supports, the key to both better health outcomes and economic recovery lies in a system that encourages people to stay at work and provides the right support to enable them to do so. GPs cannot, and should not, bear the burden of making these complex decisions. The time for reform is long overdue.
References:
1. Waddell, G., & Burton, A. (2006). Is work good for your health and well-being? TSO. https://huddersfield.box.com/s/kmyygl6clmsap4m3femp6wb7joaxd87d
This is the most obvious bit of information that ever existed.
When competing with people struggling to see their GP with cancer, no GP is going to sit with a GP for 30 minutes to discuss back to work measures.
When workplaces organise occupational health reviews, they normally use practitioners much cheaper than a GP to do this work.
And if employers want more details back to work type notes……. they need to pay for it.
Sign them all off until they take it off our hands muahahaaa
I have a Diploma in Occupational Medicine and I’m sure if there was time, money, and patient consent for job roles/tasks that I would be able to support them with the assessments. Shortly after I obtained my diploma I had the confidence to write notes that said “May be Fit” with adjustments. After the third patient came back saying “my boss says can you just give me a proper sick note instead” I started focusing my time and efforts on things I can actually influence.
Hybrid model GPs sign first 4 weeks of sickness. After that occupational health center run by council. Problem solved.
GPs should retain the power to issue sick notes.
Having worked years in inner city practices with the highest levels of poverty, drug and alcohol abuse, pts in council housing and non-English speakers – there’s been countless times I’ve come home moaning (and sometimes chuckling) to the wife about encounters with aggressive attitude from some patients, and manipulative behaviour, and the threats of complaints etc just to get a sick note.
But I would not surrender this advocating bit of our diverse role (pain in the a*se as it is, sometimes), which is peculiar to UK general practice culture, and which touches on the medical, and the pastoral, on societal security, and undifferentiated psychology, and has a purpose much greater than the sum of the parts that the reductive, cold calculating logic of the Govt is unable to see. What jobs has it got lined up for all these people? Full employment is not even any longer part of their economic philosophy. The Govt can’t even secure work for unemployed GPs!!
If GPs keep being shortsighted and continue giving up their traditional roles (and the political power that goes with them), then what exactly is a GP for? That a nurse, an ANP, a paramedic, a practice pharmacist, and a PA can’t do….