The Allied Health Professions Health and Work Report and the fit note: Perspectives of patients and stakeholders

Abstract

Introduction

Although the role of occupational therapists in the provision of vocational support is established, there has been little research into their role in issuing Allied Health Professions Health and Work Reports or their potential to complete fit notes.

Method

Employed patients (n = 14) and stakeholders (n = 12) took part in semi-structured telephone interviews and were questioned about occupational therapy-run vocational clinics, experiences of the Allied Health Professions Health and Work Reports and their views of occupational therapists completing fit notes.

Results

Most interviewees saw the Allied Health Professions Health and Work Report as a valuable tool in affecting return to work and even employers with access to in-house occupational health predominantly found it useful in corroborating recommendations. There was consensus, amongst patients and stakeholders, that completion of the fit note by the occupational therapist could reduce the burden on the general practitioner, and potentially provide more in-depth advice via the ‘may be fit’ option. However, stakeholders strongly believed that the profile of the Allied Health Professions Health and Work Report needed to be raised nationally.

Conclusion

The potential value of Allied Health Professions Health and Work Reports in primary care is recognised. However, in order to maximise this, its profile and utility needs to be raised nationally as a matter of urgency. There was also support for occupational therapists completing fit notes.

Keywords

Return to work AHP fit note Allied Health Professions Health and Work Report primary care general practice occupational therapy

Introduction

Although occupational therapists have a recognised role in vocational rehabilitation, the responsibility for providing sickness certification has traditionally been regarded as the job of medical professionals. In 2010 the fit note was introduced, replacing the ‘sick note’, allowing general practitioners (GPs) and hospital doctors to decide if a patient is ‘unfit for work’ or ‘may be fit’ for work, subject to advice contained within accompanying notes on suggested adjustments or adaptations to the job role or workplace (Department for Work and Pensions, 2010). However, consequent research commissioned by the Institution of Occupational Safety and Health (Coole et al., 2015a) found that GPs were not fully trained in how to use it for managing sick leave and were vague in their recommendations to employers. Research investigating employer attitudes towards the fit note suggested that whilst employers welcomed the potential offered by the fit note, they did not feel that the completion and quality lived up to that potential (Kotze, 2014). Similarly, Shiels et al. (2013, 2014) reported that the fit note did not appear to be being used to the optimum benefit of patients and their employers. They found that advice was often incomplete or irrelevant, with some GPs failing to comply with official fit note guidance. Aside from the identified lack of training provided to GPs, one of the key issues identified was that some GPs did not believe that issuing fit notes was part of their role and they therefore did not want to take responsibility for them (Coole et al., 2015b).

In 2017 the United Kingdom (UK) government released the command paper ‘Improving lives: The future of work, health and disability’ (Department of Work and Pensions, 2017), which included strategies to address some of these issues. They stated their intention to reform the fit note and to carry out development work to legislate for the extension of sickness certification powers to other healthcare professionals. The paper underlined the potential use of the Allied Health Professions Health and Work Report (AHP H&WR), formerly known as the Allied Health Professions Advisory Fitness for Work Report, which was introduced in 2013 (Allied Health Professions Federation, 2013), in consultation with the Department of Health (DoH) and the Department of Work and Pensions (DWP). The AHP H&WR provides advice on a patient’s fitness for work and suggestions for possible workplace modifications, enabling them to stay in work. The AHP H&WR is designed to be used as an alternative or adjunct to the fit note, providing advice to patients and their employers, and can be used to claim sick pay but not welfare benefits.

The command paper, together with the introduction of the AHP H&WR, provides potential opportunities for occupational therapists, and other allied health professionals, to help support patients to remain in or return to work. As work is recognised as important for good physical health, mental health and wellbeing (Waddell and Burton, 2006), it is essential that patients are provided with assistance and support to undertake work, even if they are not completely work-ready. Many conditions are still compatible with, and could be improved by, undertaking work (Black and Frost, 2011).

The AHP H&WR is appropriate for the documentation of both physical and mental health work-related issues. It aims to help employees, employers and GPs understand practical modifications and strategies that may assist an individual to remain engaged with or return to work. The report is designed to be easily read and clearly identifiable as an official document, with contact details to enable employers to follow up recommendations with practitioners if necessary.

However, despite current efforts to expand the use of the AHP H&WR, there has not been any research conducted on how these reports are viewed by patients, employers, GPs and other stakeholders. The aim of this study was therefore to investigate the perspectives of patients and relevant stakeholders about the utility of the AHP H&WR, and to examine the role of the occupational therapist in providing fitness certification. Although this research is set in the UK and is a response to national UK government policies, it is likely to have overarching implications for the management of people with health problems who are trying to get back to work in other health care settings where therapists have had a role in sickness certification, for example in Australia (Papagoras et al., 2018), Canada (Johnston and Beales, 2016) and Norway (Stochkendahl et al., 2018).

Method

Ethics and governance approvals were obtained from: Health Research Authority (HRA) and Health and Care Research Wales (HCRW) IRAS 254457; Leicester South NRES Committee East Midlands, Reference 19/EM/0023, 18 February 2019; Hywel Dda University Health Board, 4 March 2019; Solent National Health Service (NHS) Trust, 15 March 2019.

Patients and stakeholders were recruited from two UK primary care study sites (involving eight surgeries) participating in the Occupational Therapy Vocational Clinic (OTVoc) study (Drummond et al., submitted 2020). The purpose of the study was to find out how this clinic might help patients to return to or remain in work. Patients were eligible if they had a self-identified mental health or musculoskeletal problem that impacted on their ability to work. They needed to be in employment and referred/self-referred to the OTVoc clinic. A purposive sample of the patients recruited to the study and who had completed a 3-month follow-up questionnaire were further approached to take part in a telephone interview to explore their views and experiences of the OTVoc intervention and more broadly about getting back to work. The intended sample size was 20 patients and we used a sampling frame in order to ensure we included older and younger patients, people with different health conditions, people from different locations and people in different types of work. We also included people at different stages of returning to work. In addition, a sample of stakeholders were also invited to take part in telephone interviews to ascertain their experiences and opinions, with an intended sample size of 10. Stakeholders approached included GPs, GP practice managers, occupational therapists and the employers of patient participants who had consented to their employer being contacted.

Individual, semi-structured telephone interviews were conducted. Interview schedules and prompts were developed by the researchers and study stakeholders. Patients and stakeholders were questioned about their involvement with the OTVoc clinic and specifically about AHP H&WRs and fit notes.

Interviews were digitally recorded and transcribed verbatim, then checked by the researcher conducting the interviews. A qualitative data package (NVivo 10, QSR International) was used to manage the data. Framework analysis (Ritchie and Lewis, 2003) was used with matrices developed in Word to present data in a case by code format. Themes and sub-themes were identified by the researcher conducting the interviews. These were reviewed and agreed by the research team.

Results

Of the 28 patients returning an interview request reply slip, 14 agreed to an interview. It was also anticipated that 10 stakeholders would be recruited; however, 12 stakeholders consented to be interviewed. Interviews took place between July and November 2019. Patient participants ranged in age from 31 to 65 years and were employed in a variety of occupations including retail assistant, nurse, HGV driver, teacher, hospitality worker, GP, park warden and health care assistant. Over 70% of all patients referred to the OTVoc clinic had a mental health-related problem. Stakeholders included: the occupational therapists operating the OTVoc clinics (n = 4); practice staff including GPs (n = 2), nurse practitioners (n = 1) and practice managers (n = 2); and patients’ employers (n = 3). Patient interviews ranged from 18 to 50 minutes in length (mean 27 minutes). Stakeholder interviews ranged from 10 to 54 minutes (mean 24 minutes). Interview findings are presented with illustrative quotations.

Content of AHP H&WRs

The AHP H&WR was regarded by occupational therapists as a good way of documenting a care plan for the patient, detailing what they were ‘going to do about their condition and how they were going to manage and work towards their goals’ (ST005 OT). It is also a ‘fantastic tool, because it starts the conversation for the employee to have with their employer’ (ST01 OT). They saw it as an official document detailing clearly the difficulties the patient is experiencing and suggesting possible solutions that can be discussed and agreed upon. Occupational therapists were aware that it may not always be possible to implement those recommendations but believed the report relays to the employer the difficulties the employee experiences, facilitates their understanding and aids the consideration of possible solutions/adjustments (such as phased return to work, reducing working hours, and managing stress, pain and fatigue).

Yeah, lots of people have taken them in to their employer, and either the amendments have been agreed, they’ve taken place. They feel like they’ve had more understanding from their employer around their condition or how they view things. I’ve had people that have had their hours changed, reduced hours to meet their needs at this time, or adjusted hours depending on them being able to get up and about and meet the tasks of the job, or meet the demands of the job. Somebody that I worked with had already had reasonable adjustments agreed but they weren’t in place. So, having it in writing again, I’m not sure if it was in writing for them the first time because that wasn’t me, that was through their employer. But from me writing it in an AHP [Allied Health Professions] fit note, then those adjustments were quickly in place (ST005 OT).

Usefulness of AHP H&WRs

Of the 12 patients who reported receiving an AHP H&WR, all found them valuable. Two patients had given the report to their in-house occupational health (OH) provider, who had used the information to support their own assessment of the patient’s capacity to work. Neither patient reported any disagreement between their OH professional and the occupational therapist completing the report.

Really, it was very helpful. And I was lucky really because I obviously was under the occupational health people at work as well. And obviously they were aware that I was part of this research programme as well. So I spoke to them and to be quite honest, both the reports, because obviously my occupational health department did a report without seeing [the occupational therapist’s], and they near enough were exactly the same. So it was very helpful that I had double, two different, independent people saying exactly the same thing about the things that I needed to be able to stay at work and to be able to function properly (S302, patient).

Of the stakeholders interviewed who commented on the usefulness of the report, one employer felt that the AHP H&WR did not add much to what they already had by way of sickness and absence procedures. Most of the other stakeholders commenting on the usefulness of the AHP H&WR found it to be of value in guiding the return to work process.

Standing of AHP H&WRs

Patients reported that all but two of their employers accepted the AHP H&WR for administrative purposes around sickness absence and qualification for sick pay. Those that did not queried them initially but accepted them once they had checked with the occupational therapist/GP surgery. The two employers that did not accept the AHP H&WR asked the patient to obtain a fit note, despite one of the patients being employed by the NHS.

Yeah in the end. It took further explanation to be honest. I handed the first one in and they said this isn’t good enough for want of a better word. That I needed to get a doctor’s report. Then I took it back to [the occupational therapist] then she explained further, you know, this is, I think, you know, it said on the back of the form or something that it can be used. So, I went back and then explained that then my workplace accepted it and there were no further issues and it was used for sick pay. But I’m guessing it’s just a case of they’ve never seen one before (W023, patient).

Of the stakeholders commenting on the standing of the AHP H&WR, one employer explained that her staff were required to be seen by their own OH doctor, making the report redundant. She made some criticism of the AHP H&WR as being ‘woolly’ and not very useful for large companies that already had comprehensive sickness absence procedures, with in-house services. By comparison, a practice coordinator reported that the AHP H&WR was very beneficial for the patient and some understanding employers, but admitted that even within their own organisation, the NHS, some staff were unfamiliar with the report. Going forward, she stated that occupational therapists needed to be given authority to sign fit notes to simplify the process and increase the credibility of the profession. A practice manager suggested that there may be trepidation from employers to accept a document that is signed by an unfamiliar profession rather than a doctor. They also questioned whether occupational therapists should be given this authority as they felt that it is GPs who have the responsibilities, knowledge, skills and experience to assess the clinical implications of a patient’s diagnosis.

It depends again, it’s all on what are the clinical implications. What is the diagnosis? What are the conditions; what is the care management plan of the patient; and they, and you have the GP with their responsibilities and their knowledge, skills and experience as regards to that. Whereas another profession, it’s all about, like occupational health, as I said … occupational health, how are they to interpret that? But it’s the other implications, the underlying factors of health and they may be not aware of. So, it’s all about a balancing act and at the end of the day, you know, outcomes for all stakeholders (ST002, Practice Manager).

Some occupational therapists were not sure if employers accepted the AHP H&WR as evidence for sick pay purposes. They thought that many employers may still request a fit note from the GP. Other occupational therapists felt certain that their reports were accepted, at least by large organisations. One occupational therapist suggested a different procedure would be required for patients who were receiving benefits/universal credit who wanted to be able to go back to work in the future: she suggested that, in some cases, the occupational therapist could provide the functional assessment of the individual and refer to other members of the multi-disciplinary team at the primary care level (notably the GP, nursing staff and physiotherapists) to provide a holistic account of a person’s situation.

Utility of the AHP H&WR

One patient felt that the AHP H&WR had stopped the employer ‘rushing’ her back into work, allowing for a more supported and structured return. The same patient felt they had been provided with a more suitable work environment on the basis of the occupational therapist’s recommendations. Another patient used the AHP H&WR as a confidence booster when negotiating a return to work with her employer.

It gives me a bit of confidence to deal with my employer when I need to say no to work when they’re asking me to work, and I need to feel strong to say no, I'm doing it, you know, I can’t do this. I have this as a back-up if you like (W052, patient).

One occupational therapist described how, on one occasion, the information on the AHP H&WR was used by an employer against their employee, by suggesting that if the person required that number of adjustments in order to do their job then they probably were ‘not fit and safe to do their job’. However, the sessions with the occupational therapist made the person realise how her workplace contributed to her ill health and she built up enough confidence to challenge her employer and seek to change her employment.

It was interesting actually, because I think we’d had a couple of sessions actually before we got, so on the second session we’d written the fit note, or the health and wellbeing whatever it’s called now. And she had built up enough confidence and understanding of what was going on in the workplace and how it was contributing to her ill health, that she kind of said well if that’s the case then I’d better go, and she walked out, and they came after her and made the adjustments…. She basically called their bluff. I think I’ve got to the point where her case is closed and I haven’t really looked at her notes, obviously it’s not always appropriate. But from my last look she’d actually left that employer and secured employment somewhere else. Because I think in the course of the conversation she and I had, her employer was not a nice employer and the adjustments that she needed were not at all outrageous (ST004, occupational therapist).

The fit note and the AHP H&WR

One NHS employer described accepting the AHP H&WR as evidence for sick pay. She preferred it to the GP-completed fit note as it contained additional information such as difficulties, recommendations, goals and other comments.

There’s a little bit more information around yeah, any difficulties, any recommendations, goals and comments, which isn’t on the doctor’s note. But personally, I wouldn’t, I’m quite happy with it. There’s actually more on it than there is on the GP fit note and I’m aware of, you know, the pressures in primary care, I think it’s great if they can accept another competent health care professional to make the assessment (EM003, health service employer).

Patients generally felt that the completion of the AHP H&WR was more of a two-way process, with discussions taking place between the patient and occupational therapist, rather than with the GP-completed fit note, which tended to be more hands-off. Patients also felt less rushed than they did in the restricted time available for a GP appointment, allowing them more time to discuss their work demands. Patients lamented the lack of GP appointments available at their surgeries, citing the AHP H&WR as being the preferred option as it was easier to get in to see the occupational therapist.

I think the difference with the AHP one is that there is ongoing understanding about it. I think with a doctor, because of the limited time, the difficulty in getting in to see a GP, you could go in and just say I’m still feeling rubbish, I need another month, and they’d probably write it off. Whereas with [the occupational therapist] it’s been more, you know, she’s given it me either for a month or 2 weeks or blah-blah-blah. You know, but I think it’s been more on an understanding of how I am at that particular time, rather than oh you need another sick note, here you go (W045, patient).

The GPs interviewed found the extra information contained within the AHP H&WR very useful when writing a fit note. However, they felt that patient appointments made specifically for fit note provision were a waste of their time and expertise. They commented that occupational therapists were in a better place to make a thorough assessment of patients’ work and health needs due to their better understanding of workplaces and demands. The occupational therapist was also seen to have more time for in-depth discussions with patients. The GPs supported the idea of occupational therapists signing fit notes, although one GP thought that this may require some input from both GPs and occupational therapists with some more complex medical conditions. The GPs described their patients finding the AHP H&WR very valuable in conversations with their employers. A mental health nurse also agreed that it would be very helpful if the occupational therapist could complete and sign the fit note instead of the GP.

I thought it was brilliant that they could do that, that they could actually have their own little recommendations and that they could liaise with employers if patients were keen. I just thought it just added a really nice extra bit, because we don’t, as a doctor, you know, the patients come in and they say I do this job, and I sit there going well I don’t even know what that is, I don’t know what that means (ST008, general practitioner).

All occupational therapists viewed the AHP H&WR positively and believed that if they were also able to fill out and sign the GP fit note, it would free up GPs’ time and save the patients from having to book and attend separate appointments.

Discussion

The findings suggest that there is a consensus across both patient and stakeholder groups supporting the use of the AHP H&WR. There was also support for the occupational therapist potentially completing and signing fit notes in place of the GP. Participants found the information contained in the report of value in negotiating or planning a return to work. Even those patients and employers who had access to in-house occupational health services acknowledged that the report could provide additional back-up. There were no reported areas of disagreement between the OTVoc occupational therapist completing the AHP H&WR and the in-house occupational health assessments.

Previous research into the utility of the fit note has suggested that ‘may be fit’ notes completed by a GP are not providing the structure and recommendations required by employers in order to support their employee in returning to work. This was despite the GPs included in their research receiving occupational health training (Dorrington et al., 2018). In a survey of fit notes for the DWP, Shiels and colleagues (2013) found that only 12% of patients surveyed had been given a ‘may be fit’ note. Over a third of these had no further advice provided by the GP. This lack of advice and information on ‘may be fit’ notes potentially indicates that an AHP H&WR containing information that can support employers in effecting a return to work for their employees is a preferable alternative.

Demand for fit notes rose almost 9% in the 2 years from 2016/2017 to 2018/2019, with GPs issuing 8.7 million fit notes in 2016/2017 compared to 9.5 million in 2018/2019 (digital.nhs.uk, 2019). Coupled with the national shortage of GPs, this places an increasing burden on GPs in primary care, where the timescale for obtaining an appointment has increased to weeks rather than days. This was echoed by the GPs interviewed in our study, who felt that appointments for fit note provision were not a good use of their time. They also felt that the occupational therapist was better placed to carry out a thorough assessment than GPs were. With many employers demanding fit notes after only 3 days of sickness absence, the pressure on the service is growing. The British Medical Association GP Committee have called for the DWP to extend the period of self-certification from 7 to 14 days in order to improve access to overstretched GP services (Campbell, 2016). Despite the Department for Health and Social Care and the DWP acknowledging that the AHP HWR is suitable evidence for statutory sick pay (SSP), it would appear from our findings that not all employers are aware of this. Although there is obviously a consensus that the current sickness certification system needs to be overhauled, until there is legislation in place to implement this, it is unlikely that there will be any change. With these issues in mind, it would seem expedient to raise the profile of AHPs both in the provision of workplace advice and in the utility of the AHP H&WR within the sector. This would not only provide evidence for sick pay but would also provide the employer with advice and information on possible work modifications, potentially supporting a prompt return to work. Patients reported that the AHP H&WR gave them a feeling of empowerment, putting the responsibility for their return to work back with them. Patients liked that the preparation of the report was a ‘two-way process’ and preferable to the ‘hands-off’ approach adopted by GPs when completing the fit note. This very much fits with the occupational therapy practice of person-centred care and shared decision-making, where the patient is an equal partner in forward planning.

Our findings suggest that the AHP H&WR is a valuable resource for both patients and stakeholders. However, not all NHS patients or stakeholders are aware of it, or the fact that it is a government-sanctioned document. The role of the occupational therapist has been underutilised (Chamberlain et al., 2019) as their broad training in both physical and mental health is a hitherto untapped resource in service delivery within general practice. It would also seem pragmatic and time-efficient if AHPs and GPs could both complete and sign the fit note. This could potentially save GP time and increase the number of ‘may be fit’ notes being issued. Given the positive impact on physical and mental health, this could only be a good thing for patients, employers and the economy. The use of the AHP H&WR outside the context of the NHS should also be considered. There is clearly potential for its use by independent occupational therapists and allied health practitioners working in private practice, vocational rehabilitation and case management.

Although this study was a relatively large qualitative study, there were limitations. Arranging the interviews required a lot of flexibility from the research team: many interviews were conducted outside normal working hours to suit the participants, and interviews often needed to be cancelled and re-arranged at short notice by both clinical and patient participants. There were often problems in contacting participants, particularly the patients, as many were not keen to answer their phone to a number they did not recognise. There were particular difficulties in recruiting employers, which had been anticipated to some degree, but this was an ongoing challenge as many patients were understandably not happy to give the research team access to their employer. Finally, it is recognised that those people who agreed to be interviewed may have been a biased sample: there may have been people who were very happy, or conversely very unhappy, with the OTVoc who did not want to participate in the interviews.

In conclusion, although the potential value of the AHP H&WR in primary care is recognised, and there is generally support for its use, there were some frustrations around its standing and even its name. The current name is cumbersome and this may be part of the difficulty in promoting its use: in order to maximise its potential and the role of occupational therapists, and indeed other AHPs, in the work health agenda, its profile and utility needs to be raised nationally as a matter of urgency. There was also support for occupational therapists completing fit notes, which also seems sensible given the overwhelming workload of GPs. The suggestion of using AHPs and nurses has also been made by others (Cooper, 2010; Thomson and Hampton, 2012) and, indeed, there have even been suggestions that doctors should not be involved in sickness certification (Massey, 2019). Although this research was conducted in the UK, there are clear implications for work rehabilitation programmes and general management in other countries, even those where the healthcare system may be configurated differently. Getting people back to work is an international issue (Cancelliere et al., 2016).

This study has been conducted at a pivotal time when there will be changes in GP contracting to include the recruitment of occupational therapists in primary care (NHS England and BMA, 2020). This underlines the need for further research to improve the current management of people with work-related health issues, including who should sign and monitor fit notes and the roles of AHPs and nurses. occupational therapists are central to this agenda and should be ready to embrace and lead potential new opportunities.

Key findings

The AHP H&WR is regarded as a valuable tool in affecting a timely return to work.

There is support for occupational therapists to complete and sign the fit note, potentially saving GP time.

What the study has added

The study has provided important patient and stakeholder perceptions on sickness certification and specifically on the AHP H&WR.

Footnotes

Acknowledgements

The research team are grateful to the staff, patient and employer study participants. They are also indebted to the staff at the Solent GP Surgery and at South Pembrokeshire GP Cluster, who supported the study. They are also grateful to Joanne Ablewhite and Grit Ansari for their administrative assistance.

Research ethics

This study was conducted as part of the OTVoc (Occupational Therapy Led Vocational Clinics in Primary Care) Study. Ethical and governance approvals were obtained from: Health Research Authority (HRA) and Health and Care Research Wales (HCRW) IRAS 254457; Leicester South NRES Committee East Midlands Reference 19/EM/023, 18 February 2019; Hywel Dda University Health Board, 4 March 2019; Solent NHS Trust, 15 March 2019.

Consent

All participants provided written informed consent to participate in the study.

Declaration of conflicting interests

The authors declare no potential conflicts of interest with respect to the authorship, research or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This research was funded by a Joint Work and Health Unit Challenge Fund Grant, Reference number CF\100261.

Contributorship

CC, GS and AD designed the study. All authors contributed to the data analysis plan. Data was collected by FN. The analysis and interpretation of this data was conducted by FN and CC with support from AD. FN wrote the first draft of the article, all authors commented on and/or amended this and all authors read and approved the final manuscript.

ORCID iDs

F Nouri

C Coole

Avril Drummond

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