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Systematic review of fit note use for workers in the UK
  1. Sarah Dorrington1,2,
  2. Emmert Roberts1,2,
  3. Arnstein Mykletun3,4,5,6,7,
  4. Stephani Hatch1,
  5. Ira Madan8,
  6. Matthew Hotopf1,2
  1. 1Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
  2. 2South London and Maudsley NHS Foundation Trust, London, UK
  3. 3Department of Mental Health and Suicide, Norwegian Institute of Public Health, Oslo, Norway
  4. 4Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway
  5. 5Research Unit, Directorate of Labour and Welfare, Oslo, Norway
  6. 6Centre for Research and Education in Forensic Psychiatry and Psychology, Haukeland University Hospital, Bergen, Norway
  7. 7Department of Community Medicine, University of Tromsø, Tromsø, Norway
  8. 8Department of Occupational Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  1. Correspondence to Dr Sarah Dorrington, Department of Psychological Medicine, Western Education Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 9RJ, UK; sarah.dorrington{at}


Objectives The fit note, introduced in England, Wales and Scotland in 2010, was designed to change radically the sickness certification process from advising individuals on their inability to work to advising them on what they could do if work could be adapted. Our review aimed to evaluate the following: (1) Is the ‘maybe fit’ for work option being selected for patients? (2) Are work solutions being recommended? (3) Has the fit note increased return to work? (4) Has the fit note reduced the length of sickness absence? We considered the way in which outcomes vary according to patient demographics including type of health problem.

Methods Studies were identified by a systematic search. We included all studies of any design conducted in the UK with working age adults, aged 16 or over, from 1 April 2010 to 1 Nov 2017. Risk of bias was assessed using a modified Newcastle-Ottawa Scale.

Results Thirteen papers representing seven studies met inclusion criteria. In the largest study, ‘maybe fit’ for work was recommended in 6.5% of fit notes delivered by general practitioners (GP; n=361 801) between April 2016 and March 2017. ‘Maybe fit’ recommendations were made in 8.5%–10% of fit notes received by primary care patients in employment, and in 10%–32% of patients seen by GPs trained in the Diploma in Occupational Medicine. ‘Maybe fit’ was recommended more for women, those with higher socioeconomic status, and for physical, as opposed to psychiatric disorders. The majority of fit notes with the ‘maybe fit’ option selected included work solutions. There was inconclusive evidence to suggest that the introduction of the fit note has reduced sickness absence among patients in employment.

Conclusions Fit notes represent a major shift in public policy. Our review suggests that they have been incompletely researched and not implemented as intended.

  • public health
  • disability
  • primary care
  • fitness for work
  • mental health

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  • Contributors The authors jointly conceived the study question and designed the review. SD and ER conducted the review. SD, SH, IM and MH planned the review. SD and ER assessed the titles and abstracts identified by the search and reviewed the full text of the remaining articles for inclusion. Any discrepancy was resolved by discussion, and where agreement could not be reached MH was consulted. SD drafted the text, which was commented on by ER, SH, IM, AM and MH.

  • Funding SD is funded by the Donald Dean Fellowship in Occupational Mental Health from the Royal College of Psychiatrists. This paper represents independent research in part funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust, King’s College London and the Royal College of Psychiatrists.

  • Disclaimer The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health, or the Royal College of Psychiatrists.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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