Fit Notes Issued by GP Practices, England December 2020

Background

The Statement of Fitness for Work (the Med3 form or 'fit note') was introduced in April 2010 across England, Wales and Scotland.  It enables doctors to give advice to their patients about the impact of their health condition on their fitness for work and is used to provide medical evidence for employers or to support a claim to health-related benefits through the Department for Work and Pensions (DWP).

In 2012 DWP funded a project to provide GPs with the ability to produce computer-generated fit notes (eMed3) and this included the capability to collect the aggregated data generated.

When is a fit note required?

Fit notes are issued to patients by doctors following an assessment of their fitness for work. A fit note is issued after the first seven days of sickness absence (when patients can self-certify) if the doctor assesses that the patient’s health affects their fitness for work.  The doctor can decide the patient is 'unfit for work' or 'may be fit for work subject to the following advice...' with accompanying notes on suggested adjustments or adaptations to the job role or workplace.

While they can be written by hand, most fit notes provided by a GP are now computer-generated.

What is a fit note episode?

An episode is the same period of sickness covered by one or more fit notes. For this publication, an assumption has been made that where there is more than one fit note and there are seven or fewer days between the end of one fit note and the beginning of the next, these fit notes relate to the same period of sickness. This will not always be the case and means some episodes may be made up of different periods of sickness. The diagnosis and gender assigned to the first fit note in the episode are maintained for the whole sickness episode.

It has been possible to calculate an episode based on a linking identifier included in the data extraction. All episodes in the dataset are completed episodes, that is, there is a final fit note in the episode with any later fit note with the same linking identifier having a start date that is 8 or more days later. Fit note data was collected from December 2014, consequently, episode data is available from April 2015 to capture full episode history. 

Legal basis for the collection 

On 26 October 2015, the Department of Health granted a Secretary of State Direction under section 254 of the Health and Social Care Act (2012) to the Health and Social Care Information Centre (now NHS Digital) to establish systems to enable the collection of anonymised fit note data from English GP IT systems on behalf of Department for Work and Pensions (DWP).

The Direction also requires that patients who have objected to their data leaving their general practice will be omitted from the fit note data collection. NHS Digital has instructed the GP system suppliers to ensure that no data is extracted for patients who have objected.

Only computer-generated fit notes from GP Practices within NHS England form the basis of the data collection.

Any fit note not generated by a GP IT system is not included for example:

• hand-written fit notes provided by GPs
• medical certificates provided by private doctors
• fit notes provided by hospital/secondary care doctors
• fit notes for patients who objected to having their data extracted. 

What this collection does not tell us

1. The data does not cover all GP practices. Caution must be taken when making comparisons at regional or CCG level as data coverage must be considered.
2. Fit note data will provide information on the patterns of certification of fitness for work by GPs, rather than on the patterns of long-term sickness absence from employment. Fit notes are issued for either benefit or employment purposes but currently there is no means for a GP to record the purpose of issue, nor is it a requirement for the GP to establish the employment status of the patient for fit note purposes.
3. The data is not available at an individual level. Although fit note information is entered by the GP at an individual level, it is aggregated before extraction from the practice and presented in an anonymised form. Where necessary, additional measures such as small number suppression are used to ensure that no data is patient identifiable.
4. The age of the patient does not form part of the data extraction.
5. The data does not provide a reliable picture of the working days lost to illness because:
   • only fit notes issued electronically in GP practices are included (hand-written fit notes, fit notes issued by secondary care or hospital doctors, medical certificates provided by private doctors and fit notes for patients who objected to having their data extracted are excluded)
   • any short-term absences up to seven days will not be covered as a fit note is not required
   • for longer absences, the fit note duration does not cover the initial 7-day period where most employers allow staff to self-certify
   • not all fit notes are issued for employment purposes
   • an individual can be issued a fit note as ‘may be fit for work’ which would allow them to return to work following advice
   • not all employers require their employees to provide a fit note.
6. The number of fit notes issued in each period does not relate to the number of individuals issued with a fit note in the same period. This is because an individual patient can have more than one fit note issued in the same period, either for the same episode of illness or for a different episode. 

Data coverage

The 18 - 65-year-old patient population is used as a proxy for working age for calculations per 100,000 GP practice population.

Fit notes are issued to show to an employer for sick pay purposes or to claim sickness related benefits from DWP. The age of the patient is not part of the fit note data collection, but a fit note is generally only required for a person who is of working age.

There are two gaps in the data.

1. Data from patients who have made a prior objection to their data leaving the GP practice for purposes beyond their direct care are excluded. Data collection for any patient who registers an objection subsequently will be excluded from the point this is registered. We do not know how many patients have made an objection, nor any of their characteristics.
2. Data for the period 29 January 2018 to 4 March 2018 for GP practices with Vision as a system supplier have been under-reported due to a technical issue.

This will only impact on fit notes for this period, episodes may be impacted for longer. For this publication, an episode can consist of a single fit note (where there is more than seven days between the end of one fit note and the beginning of the next) or of many fit notes where there is more than one fit note and there are less than eight days between the end of one fit note and the beginning of the next.

Episode data may be impacted as:

• episodes consisting of one fit note will be under-reported
• episodes which started before this period and consist of more than one fit note may end early due to the lack of a continuation fit note
• episodes which started during this period and consist of more than one fit note where the starting fit note was not reported would result in the number of fit notes in the episode being under-reported.

Reasons fit notes have been excluded from the publication 

Where data was received from a single practice in a CCG, all fit notes from that practice have been excluded from the publication. This is to ensure individual practice information is not included.

Fit notes with a missing Linking ID (an anonymised identifier for an individual patient) have been removed due to failing basic data quality checks.

Fit notes which mapped to ICD-10 chapter XXII (Codes for Special Purposes) have been excluded from this publication.

Under reporting  

1. Data for the period 29 January 2018 to 4 March 2018 has been under-reported due to a technical issue, consequently no data submissions were received practices using Vision system supplier from during this period.

Duplicated fit notes  

There are number of fit notes that have the same content and were issued at the same time to the same person. Each fit note has a different unique ID consequently all of these are included in the count of fit notes, but they account for less than 1% of the total number of fit notes issued each month.

The underlying cause of this duplication is not known, and the investigation is ongoing, but it has been impacted by the advent of Coronavirus (COVID-19).

Data will be extracted for publication in the first week of the month in which it is published.

• The start date will always be the 1 April of the relevant financial year.
• The cut-off date is the last date the data was updated in the eMed3 SQL table and is set to the last date of the month prior to publication. This is necessary as fit note data is received on a weekly basis and this establishes a static time frame.
• The cut-off date is 3 months after the end date for the reported data to allow for data being submitted in an untimely manner. A 3-month lag was established as the necessary length of time allowed to elapse for data to stabilise. For example: data published in April 2020 would have an end date of 31 December 2019 and a cut-off date of 31 March 2020.

This publication is published on the NHS Digital website every quarter and all the data tables are available free of charge.

Metadata for the CSVs can be found at the bottom of the page.

This is a ‘cumulative’ data collection. Weekly data will continue to be added to the existing database. The value of data items may change as data is added.

For example:

1. Number of fit notes may increase as historical data is received
2. Fit note episode duration may change if there is issue of new fit notes for a patient.

Where patients change GP practice their new fit notes will be extracted by the supplier from the new practice. If records have been transferred by GP2GP, the linking ID will allow linkage of these patients fit notes. Where records are manually transferred to the new practice, the linking ID is not expected to continue.

All data for all reporting periods is updated in each quarterly publication. From April 2019 all publications will contain data from practices who have TPP as their system supplier (which was not previously available) and accounts for one third of practices in England, consequently publications from this date may not be comparable to previous publications.

In April 2020 - 14 NHS England Regional Local Offices were replaced with 42 Sustainability and Transformation Partnerships (STPs) as the higher-level health authority, in addition of the 191 CCGs some merged to create 135 CCGs. Learn more about these geographical changes. 

In April 2021 - a series of mergers took place across 38 CCGs resulting the the number of CCGS falling from 135 to 106. These mergers have a legal date of 1 April 2021 but an operational date of 1 October 2021 for this reason the Q3 2020-21 publication does not contain CCG mapping consistent with the new configurations as many are not yet operational. This has resulted in a slightly higher number of unallocated fit notes for 2020-21, but this is less than 0.02% of fit notes issued.

Coronavirus

The expectation is there will be fewer fit notes issued during the coronavirus (COVID-19) outbreak from March 2020 due to several factors, e.g. shielding, self-isolation or furlough .

Fit notes are used as medical evidence for employers on a patient’s fitness for work or to support a claim for health-related benefits through the Department for Work and Pensions (DWP). During the COVID-19 outbreak the only instances where GP practices can issue fit notes are for patients who:

1. have a pre-existing fit note that is not related to COVID-19 and need to be reviewed
2.  need a fit note for any reason not related to COVID-19

Isolation notes rather than fit notes provide employees with evidence for their employers that they have been advised to self-isolate due to coronavirus, either because they have symptoms or they live with someone who has symptoms, and so cannot work.

Data is not available for number of people shielding; in receipt of an isolation note or furloughed who were in employment or in receipt of benefits prior to the advent of COVID-19, consequently it is not possible to ascertain the impact on the number of fit notes issued. Patients who became unwell not due to COVID-19 whilst they were shielding in isolation or furloughed and would normally need a fit note may not need one.

Those in employment would not receive a fit note in the following cases:

1. Shielding - clinically extremely vulnerable patients are advised to take extra precautions during the peak of the pandemic in England. This is known as ‘shielding’
   • “People who are ‘Shielding’ can continue to work from home if they are able to do so. If not, the letter advising them to shield can be used as proof of their inability to work not a fit note.”
2. Self-isolation is when do not leave home because they have or might have coronavirus (COVID-19) for example they
   • have symptoms of coronavirus
   • live with someone who has symptoms of coronavirus
   • are in a support bubble with someone who has symptoms of coronavirus
   • have been told to self-isolate by a test and trace service
   • If an employee is well enough to work, and can work from home, they do not need an isolation note
   • Will get an isolation note if needed, not a fit note
3. Furloughed - If employer and employee agree, the employer might be able to keep the employee on the payroll even if they are unable to operate or have no work for you to do because of coronavirus. This is known as being ‘on furlough’
   • Employers can claim for staff furloughed from 1 March 2020
   • Will not be issued with a fit note

Similarly, those not in employment may be shielding or in self isolation in which case the letter advising them to shield, or the isolation note would be used as proof rather than a fit note. For people who need to claim benefits including Employment and Support Allowance (ESA) or Universal Credit (UC) due to COVID-19 no fit note is required.

Furloughed staff

DHSC press release: Online isolation notes launched - providing proof of coronavirus absence from work

BMA issued guidance to GPs

Department for Work and Pensions guidance for Employment and Support Allowance and Universal Credit claimants

Shielding update: Letter to the NHS – NHS England

COVID-19: guidance on shielding and protecting people defined on medical grounds as extremely vulnerable

NHS check an isolation note – What you need to know as an employer