Fit note reform needs employers

The UK government’s fit note pilots have landed in a part of working life that has long been treated as administrative rather than operational. A note is issued, an employee is signed off, and the formal process appears to move forward. In practice, the difficult decisions begin after that point: whether duties can be adjusted, whether hours can be reduced, whether team workloads can be reshaped, and whether someone remains connected to their job rather than drifting out of it.

That is the territory these pilots are trying to reach. Announced this week, the changes will be tested through four pilots in England, covering up to 100,000 appointments over the course of a year. Some participants will receive an initial fit note from a GP and then move into follow-up support delivered by community health workers. Others will go through a separate service staffed by clinical and non-clinical practitioners, without an initial GP-issued note, with the aim of producing more tailored stay-in-work and return-to-work plans.

The case for reform is clear enough. Around 11 million fit notes are issued each year, and more than nine in ten still declare that a person is not fit for work. The government’s own call for evidence found that only 29% of primary care staff see issuing fit notes as a good use of GP time, while six in 10 employers regard the current process as ineffective in supporting employees’ work and health needs. The criticism is not only that the system is slow or blunt. It is that it often settles status without creating a practical route forward.

That gap matters because absence is rarely managed through paperwork alone. Once someone is off work, the questions move quickly into line management, team design, and operational judgement. Can the role be altered for a period? Can customer-facing work be reduced? Can physical demands be limited, or hours staggered? Is there occupational health support in place, or does the line manager end up carrying the conversation with little structure and even less confidence? A fit note can record a condition. It cannot, on its own, organise a return.

The pilots are intended to do more than alter the point of certification. They will test models designed to keep employees connected to work from the first day of absence, including conversations between the individual, the employer, and a trained professional about support and reasonable adjustments. That is a more ambitious proposition than simply diverting administrative work away from GPs. It moves the system closer to the reality that return to work is usually shaped by a chain of small workplace decisions rather than a single clinical judgement.

Ben Willmott, head of public policy at the Chartered Institute of Personnel and Development, put the problem directly: “The current fit note system is not working for anyone as a way of supporting people back to work, whether that’s employees, GPs or employers. These pilots can provide useful insights that can lead to the development of a much more effective and joined up system.”

His point goes beyond dissatisfaction with the present system. The deeper question is whether employers are equipped to play the part reform assumes they can play. The answer varies sharply. The government’s Keep Britain Working review, published in March, found that occupational health provision remains highly uneven. In 2024, 45% of workers had access to occupational health support. Among large employers, 92% offered some form of provision. Among small employers, that figure fell to 18%.

That disparity sits against a labour market that is already cooling at the edges. Vacancies fell to 705,000 in the three months to April, unemployment reached 5.0% in the first quarter, and regular pay growth slowed to 3.4%. In a softer market, businesses often have less room to absorb absence through spare capacity, backfill hires, or looser workloads. The challenge of making adjustments becomes sharper, especially in smaller organisations, and in roles that cannot easily be redesigned from a desk.

That is why employer involvement cannot remain a broad aspiration. It needs structure. Who joins the conversation, and at what point? What information can be shared, and with whose consent? What sort of workplace adjustments are realistic in a warehouse, on a shop floor, or in a care setting where duties are tightly defined? How much discretion does a line manager have before HR or occupational health takes over? A reformed system will need to answer those questions with much more precision than the current one does.

Willmott welcomed the direction of travel, but his support came with a condition. “It’s encouraging to see a focus on enabling three-way conversations between patients, employers, and trained health professionals. This approach has real potential to deliver personalised adjustments and timely support to help people stay in or return to work,” he said. “However, greater clarity is needed on how employers will be involved in practice. Employers must have a clear role and input into what support and opportunities they can realistically provide.”

That clarity will determine whether the pilots change outcomes or simply reroute process. A better fit note system should reduce unnecessary GP administration, but that alone will not keep more people in work. Progress will depend on whether the new arrangements produce decisions that are specific enough to act on, early enough to matter, and grounded enough in workplace reality to hold.

The strongest version of reform would leave fewer employees suspended between illness and work, fewer managers relying on guesswork, and fewer businesses treating absence as a binary state. A different route through the health system can help. The harder task is building an approach that recognises return to work as a shared responsibility, with employers fully inside the process rather than waiting at the edge of it.