Guidance

Who can issue fit notes: guidance for healthcare professionals and their employers

Published 1 July 2022

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Acknowledgements

The Department of Health and Social Care (DHSC) and the Department for Work and Pensions (DWP) convened an implementation group with representatives from the four UK Governments, relevant professional bodies, regulators and statutory education bodies to provide expert input and advice on implementing reforms to the fit note system.

Health Education England (HEE) was commissioned to work with similar stakeholders to coordinate the development of UK wide, non-statutory guidance to support both healthcare professionals (HCPs) and their employers in understanding who is best placed to certify fit notes.

It has been developed in consultation with:

  • The Royal College of Occupational Therapists
  • The Royal College of Nursing
  • The Chartered Society of Physiotherapy
  • The Royal Pharmaceutical Society
  • The Royal College of General Practitioners
  • The General Pharmaceutical Council
  • The Nursing and Midwifery Council
  • The Health and Care Professions Council
  • The British Medical Association
  • Scottish Government
  • Welsh Government
  • Northern Ireland Executive
  • Health Education and Improvement Wales
  • NHS Education for Scotland
  • NHS Employers
  • NHS England and Improvement
  • Department of Health Northern Ireland
  • The Department of Health and Social Care
  • The Department for Work and Pensions
  • HEE People’s Advisory Forum Representative

Glossary

Term Expansion
AHPS Allied Health Professionals [footnote 1]
Allied Health Professional (AHP) Health and Work Report AHP Health and Work report 2021
DA Devolved Administration
DHSC Department of Health and Social Care
Doctor Registered Medical Practitioner (RMP)
DWP Department for Work and Pensions
elfh E-learning for Healthcare
HCPs Healthcare Professionals. In this guidance, the term healthcare professionals is used to relate only to members of the five professions who can certify fit notes. These are doctors, nurses, occupational therapists, pharmacists and physiotherapists.
HEE Health Education England
Nurse Registered nurse
Other HCPs Is used in this guidance to describe healthcare professionals who are not currently able to certify fit notes.
Patient /Person/People and Individual These terms are used interchangeably throughout the guidance to convey that the wide range of HCPs now certifying fit notes may not always use the word ‘patient’ to describe their clients/service users/customers etc.

Chapter 1 - Introduction and context

Overview and summary

1.1 This guidance has been developed to provide advice to doctors, nurses, occupational therapists, pharmacists, physiotherapists and their employers about certifying fit notes. The guidance is designed to provide a summary of the knowledge, skills, experience and training these healthcare professionals (HCPs) are expected to have before certifying fit notes.

1.2 This non-statutory guidance has been developed with expert input from the four UK Governments, relevant professional bodies, patient representatives, regulators and statutory education bodies. It includes broad principles applicable across all those involved in certifying fit notes, with chapters covering:

  • Eligible HCPs - the experience and competence required for individuals to certify fit notes;
  • Employer - the responsibilities and duties of those employing HCPs enabled to certify fit notes; and
  • Governance - the relevant governance considerations including professional regulation and codes of practice.

1.3 There are several cross-cutting issues relevant to both individual HCPs and employers, as such it is recommended that this guidance is read in full prior to certifying fit notes or making any decisions about how this task is undertaken in the workplace.

1.4 This guidance sits alongside two other key resources:

1.5 It is important that individuals and employers consider the above resources, alongside this guidance, to understand: who should undertake fit note certification; how to practically certify a fit note; what fit note certification entails.

Context and Reasons for Change

1.6 It is generally accepted and there is evidence [footnote 2] [footnote 3] [footnote 4] [footnote 5] [footnote 6] [footnote 7] [footnote 8] that good quality work is good for physical health, mental health and wellbeing. Evidence also indicates that the longer someone is off work due to ill health, the less likely they are to return to employment[footnote 9]. Even if people are not fully fit, engaging with work can deliver health benefits.

1.7 Modern healthcare reflects that HCPs from a range of disciplines now play a central role in leading the delivery of healthcare and support for patients to enable them to manage their health and wellbeing. Increasingly this applies to enabling people to safely remain in or return to work wherever possible, and to manage their own health and wellbeing[footnote 10]. Whilst multi-professional working has seen some HCPs with the relevant skills and experience support work and health conversations, until July 2022 only doctors (registered medical practitioners) were legally permitted to certify fit notes.

1.8 The Department for Work and Pensions (DWP) amended legislation, with effect from 1 July 2022 to enable nurses, occupational therapists, pharmacists and physiotherapists to certify fit notes in addition to doctors (these five professions are referred to in this guidance as healthcare professionals - HCPs). The legislation is permissive, meaning that all these HCPs can legally certify a fit note, but they are not required to do so. Individuals should consider their scope of practice and ensure they have the relevant skills, knowledge and experience before undertaking health and work conversations and making decisions around certifying fit notes.

1.9 This change came following public engagement and research on the policy by DWP and Department of Health and Social Care (DHSC) through “Improving lives” (green paper 2016, response published 2017)[footnote 11], “Health is Everyone’s Business” (consultation 2019, response published 2021)[footnote 12] and a published research report (2020).[footnote 13]

1.10 There has been broad public support for extending certification of the fit note which is also reflected in the views of the stakeholders (para 1.11), who have helped shape this policy. Changes have also been supported by wider stakeholders who have indicated that the fit note should not be exclusively completed by a doctor and the system should be allowed to embrace new ways of working by involving other HCPs.

1.11 The decision as to which professions to extend certification to has been agreed following engagement with, and advice from: DHSC, Chief Allied Health Profession Officers, Chief Nursing Officers, Chief Pharmaceutical Officers, professional bodies, regulators, and policy officials across all four nations of the UK.

1.12 Enabling a wider range of HCPs to certify fit notes offers benefits for patients and the healthcare system and better recognises innovations in using a multi-disciplinary workforce to support patients. These HCPs can engage more directly with patients on matters of work and health without having to re-route requests to certify fit notes through doctors.

1.13 The changes aim to provide a seamless, faster system for patients; improve continuity of care; reduce bureaucracy in the healthcare system; and fully utilise skills by enabling relevant HCPs to conduct health and work conversations and certify fit notes. As a result of the changes, it is also expected that patients and employers will see benefits.

Legislation

1.14 A statement of fitness for work, commonly known as a fit note or ‘med 3’, is a form of medical evidence that can enable an individual to access health-related benefits or evidence eligibility for statutory sick pay (SSP). Its purpose, format and requirements are set out in regulations which cover England, Wales and Scotland. The fit note contains options to assess a person as ‘not fit for work’ or ‘may be fit for work taking account of the following advice’.

1.15 The legislation requires the HCP to undertake an assessment to complete a fit note. An assessment is defined as a consultation between the patient and HCP or consideration of a written report by another health professional. The fit note provides advice about the functional effects of a patient’s condition on their fitness for work but it does not require the HCP to have specialist knowledge of workplaces or occupational health or to suggest possible changes to a patient’s workplace or job.

1.16 Where patients are required to evidence eligibility for SSP, provided their employer is content, they can provide alternate forms of evidence[footnote 14]. One example of this is the ‘AHP Health and Work Report’ [footnote 15] which can be completed by all Allied Health Professions, including those that are not legally able to certify fit notes.

Legislative change

1.17 In 2017 the DWP confirmed publicly their intention to reform fit notes, which at the time could only be certified by doctors and required a signature in ink to certify them.

1.18 Two legislative amendments were then made to improve the fit note and its use.

  • Removal of the requirement for signatures in ink (April 2022). This amendment removed the barriers to fit notes being completed and certified digitally so that relevant systems could be updated to simplify the processes for completing fit notes. (Wet signature fit notes continue to be accepted.)
  • Extension of certification of fit notes to a wider group of HCPs – nurses, occupational therapists, pharmacists and physiotherapists. This change legally enabled any statutorily registered member of these professions, to certify a legally valid fit note.

1.19 The legislation [footnote 16] is permissive, meaning that it does not mandate these HCPs to certify fit notes. As with any clinical task, and in line with professional regulation, individual HCPs should consider their scope of practice before undertaking health and work conversations and making decisions around certifying fit notes.

E-learning for Healthcare training (elfh) - ‘The fit note’

1.20 An online training module hosted on elfh has been developed to support HCPs in preparing to certify fit notes as part of their practice if it is an agreed part of their role. Health Education England (HEE) elfh works in partnership with the NHS and professional bodies to support patient care by providing e-learning to educate and train the health and social care workforce. Its e-learning programmes are developed in partnership with the NHS, third sector and professional bodies. The fit note training course can be accessed for free, 24/7 by health and care professionals.

1.21 The fit note training course was developed with HEE and an expert clinical sub-group. It is available on the elfh site and accessible to all relevant HCPs across all four nations from summer 2022.

1.22 HCPs starting to take on the task of certifying fit notes should complete the elfh training. The objectives of the training are to support HCPs:

  • to further develop their confidence and skills to have an effective work and health conversation and to be able to understand and communicate (where appropriate) the importance of work as a clinical outcome;
  • to use professional judgement to assess impact of a health condition on an individual’s fitness for work;
  • to be able to negotiate and develop an agreed plan with the patient about their health and work, including advice about self-management and workplace modifications (where appropriate);
  • to complete the technical steps required in the process of completing a fit note and understand options for next steps after a fit note has been certified e.g., signposting.

1.23 The training offers a wide range of up to date and relevant information that can support conversations with professionals who are new to this task in clarifying that they are suitably qualified and experienced or enhancing their skill level to allow them to proceed with confidence. The training will enable HCPs to enhance and amplify their skills to have work and health conversations, informed by the relevant policy and legal frameworks, thereby helping individuals, as appropriate, to seek work, return to or remain in work.

Chapter 2 – Eligible Healthcare Professionals

2.1 The aim of this chapter is to provide advice on the development of further knowledge, skills and experience which will support HCPs to use their clinical skills to undertake health and work conversations and certify fit notes for patients.

Certifying fit notes

2.2 When first conducting fit note certification, the HCPs who are legally able to certify fit notes should complete the elfh training modules on fit note certification and have a period of structured mentorship and support. The period of mentorship and support may be variable in length depending on the development of capability and confidence, alongside clinical experience of conversations with the person in the care of the professional about health and work, including shared decision making.

2.3 This post registration training and experience will support the development of skills to ensure the HCP is able to operate with professional responsibility and within their scope of competence to deliver the best outcomes for patients. See also Chapters 1 and 4 on scope of practice and statutory regulation.

2.4 As a minimum, the HCP should:

  • hold current registration with the relevant professional healthcare regulator;
  • have certifying fit notes as an agreed part of their role (if employed or operating under a contract);
  • be able to articulate that certifying fit notes is in their individual scope of practice;
  • be involved with the assessment, diagnosis or care planning of the patient the work and health conversation relates to or be able to form an assessment based on a written report by another HCP;
  • be acting in their professional capacity;
  • work in accordance with the requirements of their employer and/or contractual arrangements;
  • have necessary indemnity;
  • review patient medical records where appropriate e.g., to assess the duration of health condition and likely fluctuation or treatment side effects and duration.

2.5 Individuals may also wish to consider profession specific guidance, where it has been issued by the relevant professional body.

Relevant experience for certifying fit notes

2.6 The length and type of experience that individual HCPs have in this area will vary. Each HCP should ensure that they have the knowledge, skills and experience to undertake this new task in line with their individual scope of practice and be able to articulate this to their employer if it is an agreed part of their role.

2.7 HCPs are required to revalidate (renew/re-register) as a condition of their registration. This provides opportunities to demonstrate development of knowledge, skills and a reflective account of their practice relating to certifying fit notes as appropriate. Employers who wish to include this new duty in existing or new job roles will need to consider any additional relevant work-based experience they can provide to assist their HCPs.

2.8 Opportunities to gain relevant experience could include:

  • Observing an experienced HCP conducting health and work conversations and certifying fit notes;
  • Case based discussion with a more experienced HCP until competent and confident to give feedback about health and work assessment and intervention, clinical reasoning and decision making;
  • Structured mentorship, support and supervision from experienced HCPs to successfully transition their knowledge into practice;
  • Opportunities for reflection and feedback to support their approach;
  • Use of daily debrief during initial period for safety and assurance. Ongoing knowledge and skills development and working in practice

2.9 As part of ongoing knowledge and skills development, HCPs should know when to seek the advice of colleagues and mentors about a patient’s health and work needs. For example, the relevant HCP who is certifying the fit note can, and should where needed, make use of the wider expertise of their teams to inform health and work conversations and decision making with regards to the fit note.

2.10 As per the legislation [footnote 17], the HCP certifying the fit note can do so based on consideration of a written report by another health professional involved with the diagnosis or care planning of the patient. It is not necessary for the written report to be undertaken by a member of one of the five professions currently listed in regulations (para 1.8) as having the ability to certify fit notes. To note, the HCP who certifies the fit note is accountable, even when based on the written report of another health professional.

2.11 Subject to the necessary agreement of the patient, HCPs may also wish to share the information that a fit note form has been completed with other relevant professional colleagues involved in the patient’s care. HCPs should carefully consider with whom they share information about a patient’s fit note. The healthcare regulators provide guidance on patient confidentiality, including consent and implied consent, which provides useful advice on how to make a decision on the disclosure of information. When deciding benefit entitlement DWP may seek further information from professionals involved in the patient’s care. Patients give consent for this information to be provided as part of their claim and HCPs do not need to seek additional consent.

2.12 It is recognised there may be challenges for HCPs certifying fit notes when there is disagreement about the best course of action and recommendations on the fit note. Advice on communicating with patients and handling difficult conversations is covered in the elfh training package and in chapter 4. HCPs should not feel pressured to sign a fit note.

2.13 HCPs completing a fit note should be regarded as responsible for that episode of care, including responding to any requests for further information or evidence from the DWP or the patient’s employer for the duration of the fit note.

2.14 HCPs should always have regard to their professional accountability/responsibility, codes, and standards according to the requirements of their respective regulatory body (see chapter 4).

Chapter 3: Employers of healthcare professionals who may certify fit notes

3.1 HCPs that are able to certify fit notes may work in a wide variety of settings. For those that are employed, it is advised that a conversation takes place between the individual registrant and their employer about whether this is an acceptable part of their employment role when certifying fit notes in their employment setting, and the nature of this responsibility.

3.2 Legislation [footnote 18] permits fit notes to be certified by certain HCPs (para 1.8). However, it is consistent with overarching regulatory principles of good healthcare practice and ethics for individuals and their employers (where relevant) that they must first ensure they have the relevant skills, knowledge and experience to undertake this task.

E-learning for Healthcare training (elfh) - ‘The fit note’

3.3 HCPs new to the task of certifying fit notes should complete the elfh training (see chapter 1). As part of this, employers should consider how best to ensure relevant HCPs have the necessary time and space during work hours to undertake this training and receive any other relevant support (see chapter 2 and paragraph 3.7). Employers may explore incorporating this training module into internal policies or employment terms, depending on context.

3.4 All HCPs eligible to certify fit notes should have access to the resource regardless of whether or not they have an NHS email address. Once courses are completed the platform produces downloadable certificates which can be used to allow HCPs to evidence their completion of the training to their employers, including when taking up a role with a new employer. Additional information regarding the elfh training can be found in Chapter 1.

Who should certify fit notes

3.5 Employers planning their workforce should be mindful of balancing the benefits of being able to spread the task of certifying fit notes more evenly across their HCPs with the significant nature of this responsibility.

3.6 A conversation should take place with individuals whose registered profession enables them to complete this task. This should include both their responsibilities as a registered professional to work within their scope of practice (see chapter 2) and the employers’ responsibilities as their employer to provide support and training. This conversation should ensure that all individual HCPs feel confident that they are working within the scope of their competency and scope of practice before asking them to take on this task to mitigate against potential risks (see chapter 4).

3.7 As part of this, an employer may wish to consider:

  • The HCP’s confidence in their ability to take on this task: many HCPs will already have experience of supporting patients with work and health conversations or even providing advice that informs fit notes certified by doctors, whereas others – such as newly qualified HCPs – may have less prior experience and feel they need more support before taking this task on independently, so it is important to discuss with them individually.
  • Support within the employment setting for HCPs taking on this task: as explored in the elfh training module, HCPs may experience challenge from patients when having fitness for work conversations and some may feel under pressure to certify fit notes that do not reflect their professional clinical opinion. Consider how formal or informal support could be available in the workplace, from within established supervision practices, to peer mentoring from more experienced colleagues (see list of suggestions at 2.8).
  • Clarifying individual responsibility: the HCPs enabled by law to certify fit notes are expected to act at all times in accordance with the codes of practice or standards set out by their regulator and professional body. It is important to note that all such HCPs, if asked to take on this task, will be mindful of acting within their scope of practice (see chapter 4 for more information) and will need to judge their suitability to respond to fit note requests on an individual basis.

Chapter 4: Governance

4.1 The HCPs legally enabled to certify fit notes are subject to statutory regulation [footnote 19], and therefore registrants must undertake this task in a way that is consistent with their own regulator’s standards, requirements [footnote 20] and employing organisation’s policies and procedures.

4.2 Any eligible registrant starting to take on the task of certifying fit notes should complete the elfh training (see chapter 1 and 3), in line with regulatory principles relating to maintaining up to date knowledge and skills.

4.3 All the regulatory bodies [footnote 21] that oversee the professions enabled by law to certify fit notes include in their standards of practice a form of words stipulating that:

  • Registrants must recognise and be able to articulate and work within their individual competence
  • Registrants must keep their knowledge and skills up to date and relevant to their scope of practice
  • Registrants must undertake continuing professional development

Applying regulatory standards when certifying fit notes

4.4 Beyond the need to complete appropriate training ahead of undertaking new tasks, all relevant regulatory bodies include principles that are particularly applicable to taking on certifying fit notes. Employers and individual professionals should pay particular attention to the following principles:

4.5 Competence and scope of practice - The importance of recognising and working within the limits of the HCPs individual level of competence, knowledge and skills, and of seeking input from appropriately qualified colleagues when needed. This principle is applicable if for example a patient requests a fit note due to a health condition that is not within the scope of a registrant’s clinical practice.

4.6 Person-centred care - The importance of treating people as individuals, upholding their dignity and listening to their concerns and preferences, as well as responding honestly to their questions. This principle is particularly applicable when having a work and health conversation with a patient which benefits from shared understanding and joint decisions about care.

4.7 Teamwork - The importance of working co-operatively with multidisciplinary team colleagues, respecting their skills and contributions and sharing relevant knowledge with other colleagues involved in a patient’s care. This principle is relevant because patients may have health and work conversations with multiple members of the clinical team and can benefit from clear and consistent information.

4.8 Communication - The importance of communicating clearly and professionally with patients and the public, providing the information they need in a way that is easy to understand and is appropriately recorded. This is particularly relevant given that written fit notes will need to be used and understood by not only the patient involved in the fitness to work discussion but also their employer and others involved in implementing any advice in the note.

4.9 Confidentiality - The importance of treating all patient information as confidential and ensuring patients’ dignity and privacy. This is particularly relevant due to the wide number of settings in which health and work conversations may happen and means that such a conversation should not take place unless a private place for discussion is available.

4.10 Raising concerns - The importance of raising concerns or challenging poor behaviours when patient safety is at risk, even when difficult to do so, and of contributing to a culture that allows HCPs to raise concerns safely. This is particularly relevant as registrants may be asked to certify fit notes in situations that would mean practicing beyond their role, experience and competence or under pressure from a patient. They should be able to confidently refuse to do this and be supported to deal with potential pressure to act outside of professional ethical boundaries.

Considerations of employer policies and procedures

4.11 It is important for HCPs and employers (where relevant) to consider practical issues that may affect registrants’ abilities to certify fit notes in a way that complies with the above regulatory principles.

4.12 For example, in some settings a HCP may not have access to a patient’s relevant medical history and would need to consider whether a fit note could be appropriately certified in this circumstance. In other settings a HCP may be limited in their ability to connect with other members of the clinical team involved in a patient’s care, to the possible detriment of their ability to make a judgment about fitness to work.

4.13 As such it is vital that HCPs and those involved in managing and planning services consider these regulatory principles and the specific context they are operating in when making decisions about which professionals can appropriately certify fit notes to patients and service users.

Frequently asked questions

1. What is a fit note?

A statement of fitness for work, commonly known as a fit note or Med3, is an official statement from a doctor, nurse, occupational therapist, pharmacist or physiotherapist. It is issued to provide evidence of the advice a healthcare professional (HCP) has given about their patient’s fitness for work. HCPs should record details of the functional effects of their patient’s condition and this does not need to be job-specific.

Fit notes can be used by both individuals in work and those out of work:

  • For individuals in work, where the advice is they ‘maybe fit for work’, it can enable them to return to work with adjustments. Where adjustments are not possible, or where the advice is they are ‘not fit for work’, it enables individuals to gain access to statutory sick pay.
  • For individuals out of work it can be used to support a claim for incapacity-related benefits or to show that they have been unable to fulfil certain benefit requirements.

Fit notes are a useful tool to enable better conversations about work and health. This can help patients: return to work where appropriate; aid their recovery; enable them to communicate effectively with their employers about their health.

2. Who might need a fit note?

If a person is assessed as having a health condition that impacts on their ability to work they can be issued with a fit note after the seventh day of illness. The fit note is a healthcare professional’s assessment of a patient’s fitness for work. If, following assessment the patient is considered fit for work they do not need a fit note, even if it is asked for.

3. Who can certify fit notes?

Until July 2022 only doctors were legally permitted to certify fit notes. The Department for Work and Pensions (DWP) amended legislation, with effect from the 1 July 2022 to enable nurses, occupational therapists, pharmacists and physiotherapists to certify fit notes. These five professions are referred to in the guidance as healthcare professionals (HCPs).

Enabling a wider range of HCPs to certify fit notes offers benefits for patients and the healthcare system. The changes aim to provide a seamless, faster system for patients; improve continuity of care; reduce bureaucracy in the healthcare system; and fully utilise skills by enabling relevant HCPs to conduct health and work conversations and certify fit notes.

The HCP certifying the fit note can do so based on consideration of a written report by another health professional involved with the diagnosis or care planning of the patient. It is not necessary for this written report to be undertaken by a member of one of the five professions listed in regulations as having the ability to certify fit notes. To note, the HCP who certifies the fit note is accountable, even when based on the written report of another health professional.

4. Do the changes apply across the whole UK?

Legislative changes apply to all registered nurses, occupational therapists, pharmacists, and physiotherapists and doctors at point of registration in Wales, Scotland, and England.

Northern Ireland are also laying their own legislation which will mirror this.

5. What training and experience should healthcare professionals new to the task of issuing fit notes have?

The HCPs who are legally able to certify fit notes should complete the e-learning for health training modules on fit note certification and have a period of mentorship and support when first conducting fit note certification. The period of mentorship and support may be variable in length depending on the development of capability and confidence, alongside clinical experience of conversations with the person in the care of the professional about health and work.

6. Where can you access the e-learning for health training on fit notes?

The course is hosted on Programmes - elearning for healthcare and is accessible to all relevant HCPs across all four nations from summer 2022. It is titled ‘The fit note’ and should take two to four hours to complete.

7. Will HCPs be using a paper or digital fit note?

Fit notes can be certified and issued on clerical paper pads or digitally. The format of the fit note will depend on whether the HCP has access to the relevant IT systems. Currently only HCPs working in general practice, with access to the relevant IT systems, will be able to certify and issue fit notes digitally.

The introduction of an embedded digital fit note in GP IT systems followed the legislative change in April 2022, which removed the need for handwritten signatures.

Individuals working in secondary care, or without access to relevant GP IT systems, can certify fit notes clerically on paper pads, which remain valid and must be ordered directly from DWP.

8. Can HCPs working in a hospital certify a fit note?

Yes, HCPs working in hospitals who have completed the e-learning and are working within their scope of practice can and should certify fit notes in line with the guidance. If it is clear at the time of hospital discharge that a patient due to their health condition will need time off work, a fit note should be issued for the full amount of time that the patient can expect to be off work.

9. Can healthcare students on clinical practice or healthcare support workers working under delegation certify fit notes?

No, only registered HCPs can certify fit notes.

10. Can private providers now certify fit notes?

Where private providers are commissioned to deliver NHS services that cover situations in which it would be suitable to certify a fit note, such as following surgery, they are able to request clerical fit note pads directly from DWP.

Provided it follows the rules set out in regulations healthcare professionals operating privately could issue a report that can be deemed valid as a fit note. However, this should only be done if it is within their scope of practice as set out in the drafted non-statutory guidance and in line with all clinical tasks. Private providers should take into consideration the implications of issuing medical evidence for fitness for work that is offered free to NHS patients as there may be subsequent requests for additional information, particularly for DWP benefits, that claimants are not expected to have to pay for.

11. As a ‘community pharmacist’ can I provide a fit note?

As whole professions are named in legislation, any registered practicing doctor, nurse, occupational therapist, pharmacist or physiotherapist can legally certify a fit note.

Fit notes are not part of the NHS services which community pharmacies provide and community pharmacists will not/do not have access to the ‘Med3’ - which is the technical name for the fit note provided for free under NHS provision.

Fit notes should only be certified following a full assessment of a patient’s fitness for work, and therefore should be provided by a clinician with a holistic oversight of the individual’s condition.

Pharmacists working in multidisciplinary teams within general practices or hospital settings who are able to assess patient’s fitness for work, will have access to the official Med3 form.

Pharmacists intending to issue fit notes should make sure that they complete the appropriate training and meet the standards for pharmacy professionals set out by the regulator.

The intention is that ‘where’ the fit note is certified will remain the same but there will be a wider range of healthcare professionals ‘who’ are able to certify the notes.

12. Do I need access to a patient’s medical history to certify a fit note?

Individual HCPs will need to assess whether they have the necessary information to make an assessment and decision on a patient’s fitness to work, this may include having access to a patient‘s relevant medical history. As with any clinical assessment HCPs should be mindful of the potential implications of undertaking this task without access to medical records. HCPs may also wish to refer to profession-specific advice [footnote 22] and regulatory standards in this regard as professional circumstances may differ.

13. Are HCPs issuing fit notes able to make recommendations to patients about work adjustments?

The fit note should be used to give advice about the functional effects of a patient’s condition on their fitness for work in general. Where HCPs have relevant training or qualifications they can also choose to include advice on possible changes to a patient’s workplace or job.

14. What do these changes this mean for the Allied Health Professionals Health and Work Report? 

It does not change anything about this tool which can still be used as before, whereby provided a patient’s employer agrees it can evidence eligibility for statutory sick pay (see SSP guidance). The AHP Health and Work Report and the fit note are similar in content. HCPs familiar with the AHP Health and Work report should easily transition to certifying fit notes.

15. How do HCPs work with their employers to start using the fit note?

The new guidance is for HCPs and their employers to work out how to make this change in practice. It covers job roles, scope of practice and how employers can provide in house development opportunities for HCPs new to the task of certifying fit notes.

As four new professions are involved, employers may find it easier to make the changes across impacted staff together. For example, in primary care, it will be important to involve Practice Managers, GP’s, Nursing Leads, Nurses, AHP’s and Receptionists in the change.

16. If the changes are about reducing the burden on GPs, should doctors delegate requests to certify fit notes to nurses, physios, occupational therapists, or pharmacists?

A patient should be assessed by the best person to address their health condition or concern - effective triage of this will take place at a localised level in line with other clinical tasks. The guidance is clear that the HCP certifying fit notes should only do so as part of their agreed scope of practice. It is also worth noting that patients may not present as specifically requesting a fit note and that, in line with the NHS choice framework, patients can request to see specific HCPs.

17. What is the process for patient complaints about fit notes?

In common with all patient complaints, the patient is able to raise a complaint with the organisation providing or commissioning these services who will have their own complaints arrangements.

18. What further information can the Department of Work and Pensions request following provision of a fit note?

When deciding benefit entitlement DWP may seek further information from professionals involved in the patient’s care. This could be via a telephone call or a formal request for a written report. These services are contracted to healthcare professionals working on behalf of DWP (eg from Centre for Health and Disability Assessment).

Patients give consent for this information to be provided as part of their claim and you do not need to seek additional consent. The healthcare regulators provide guidance on patient confidentiality, including consent and implied consent, which provides useful advice on how to make a decision on the disclosure of information, for example, the General Medical Council confidentiality guidance (paragraph 115) states ‘you may accept an assurance from an officer of a government department or agency, or a registered health professional acting on their behalf, that the patient or a person properly authorised to act on their behalf has consented’.

Wherever possible, information collection is kept to a minimum but at times professional reports to substantiate claims are needed. This information is invaluable to ensure your patients get their correct entitlement with the minimum of disruption.

The form of the information requested will depend on which benefit the claimant is entitled to, for example most information requests regarding Universal Credit (UC) and Employment and Support Allowance (ESA) claims will be on the UC/ESA113. A full guide to medical evidence reports can be found here. You can complete these reports from your medical records and knowledge of the patient without carrying out a separate examination of your patient.

As outlined in the guidance, the healthcare professional who certified the fit note should be regarded as responsible for that episode of care, including responding to any requests for further information or evidence from the DWP or the patient’s employer for the duration of the fit note. To note, the claimant is responsible for providing the relevant contact details that DWP use to request further information.

19. What resources are available for HCPs to learn more about health and work?

20. Where can I find the details of occupational health providers?

Occupational health support can be very helpful in complex cases and when work may be affecting your patient’s health. Occupational health services are sometimes provided by NHS or local authority services. To find details of providers in your area, contact:

  1. Professions and protected titles ↩

  2. Collingwood, S. (2011). Attitudes to health and work amongst the working-age population DWP Research Report No 763 ↩

  3. O’Brien et al (2008). Sickness certification in the general practice consultation: the patients’ perspective, a qualitative study. ↩

  4. Hann M and Sibbald B (2011). General Practitioners’ attitudes towards patients’ health and work DWP Research Report 733. ↩

  5. Waddell, G. and Burton, A.K. (2006), Is work good for your health and well-being? TSO ↩

  6. Waddell, G., Burton, A.K. and Kendall, N.A.S. (2008). Vocational Rehabilitation, what works, for whom and when? TSO ↩

  7. Fylan, B., Fylan, F. and Caveney, L. (2011). An evaluation of the Statement of Fitness for Work: qualitative research with General Practitioners. DWP Research Report 780.

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  8. Lalani, M., Meadows, P., Metcalf, H. and Rolfe, H. (2012). An evaluation of the Statement of Fitness for Work: qualitative research with employers and employees. DWP Research Report 797. ↩

  9. Health in the workplace: patterns of sickness absence, employer support and employment retention. ↩

  10. 2019 Healthcare Professionals’ Consensus Statement for Action  ↩

  11. Improving lives: the future of work, health and disability. ↩

  12. Health is everyone’s business: proposals to reduce ill health-related job loss. ↩

  13. Exploring perceptions and attitudes towards the extension of fit note certification. ↩

  14. Statutory Sick Pay: employee fitness to work ↩

  15. Taking sick leave ↩

  16. The Social Security (Medical Evidence) and Statutory Sick Pay (Medical Evidence) (Amendment) (No. 2) Regulations 2022 ↩

  17. See Paragraph 1.15 for a description of the legislation. ↩

  18. The Social Security (Medical Evidence) and Statutory Sick Pay (Medical Evidence) (Amendment) (No. 2) Regulations 2022 ↩

  19. The Social Security (Medical Evidence) and Statutory Sick Pay (Medical Evidence) (Amendment) (No. 2) Regulations 2022 ↩

  20. Standards for pharmacy professionals, GMC Good medical practice, HCPC Standards of conduct, performance and ethics, NMC Standards. ↩

  21. The HCPC, NMC, GMC and GPhC ↩

  22. RPS view on pharmacists being enabled to provide fit notes ↩

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