Enabling nurses to sign off on fit notes has been a ‘positive development’, but staff shortages mean not every GP practice has implemented the change, according to new research.
Government-commissioned research published today has explored the views and experiences of healthcare professionals, employers and patients following legislative changes that meant professionals other than GPs can issue fit notes.
Nurses, pharmacists, occupational therapists and physiotherapists have been able to sign off and certify fit notes in England, Scotland and Wales since July 2022, as part of a move designed to reduce pressures on GPs.
Today’s research considers evidence on attitudes towards the reforms and whether they have been working as intended.
Positive reaction to nurses issuing fit notes
Across patients, employers and healthcare professionals, feedback suggested the extension was ‘a positive development’, particularly regarding nurses.
‘For nurses, participants tended to offer a positive view at once; for physiotherapists and occupational therapists, they sometimes took a little longer; and they had more reservations overall about pharmacists being able to issue fit notes,’ the study said.
It added: ‘Across all the groups, participants were generally positive about extending certification to nurses, except for the few who were against extension of certification altogether.
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‘There was very little discussion of either benefits or risks, though some suggested that nurses had wider training and experience which made them able to deal with a wider range of reasons or conditions for patients to be issued with a fit note.’
Public show ‘clear support’ for nurses signing off fit notes
A survey of more than 2,000 members of the public suggested less than one in five knew that nurses (18%) could issue fit notes.
But more positively, the research suggested there was ‘clear support’ for the move, with 40% of those surveyed saying nurses should be able to issue fit notes.
For the healthcare professionals now able to sign off fit notes, the findings suggest the impact had been ‘significant and positive’.
‘There was a strong sense from these [healthcare professionals] that the reform allows them to provide more holistic care, reduces waiting times for patients and avoids duplication of healthcare resources,’ it said.
‘They explained this led to more team working, better job satisfaction and improved status and morale from being able to make greater use of their professional skills and experience.’
One nurse informing the research said: ‘Being able to officially and legally sign sick notes has been a big change.
‘For 20 years I’ve been filling them in and giving them to a GP to sign. It was ridiculous that after going through a whole episode of care with a patient, I wasn’t able to do that – even though the GP was signing it without actually seeing the patient, just on my recommendation.’
Staff shortages impacting fit note changes
The research warned that despite awareness of the policy change and acceptance by GP partners that patients would benefit from the move, some study participants said it had ‘not yet been implemented due to staff shortages or current working pressures’.
‘In addition, some smaller GP surgeries mentioned that they did not have any of the relevant [healthcare professionals] working for them, so there is not anyone other than the GP available to issue fit notes,’ it said.
One employer told researchers: ‘We are one nurse down and have been for a year, so the existing nurse doesn’t have capacity to take this on. So, it didn’t make sense to ask her to.’
The research suggested that while the move has been supported, the use of extended certification was ‘limited at present’.
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The latest figures from NHS Digital show around 90% of fit notes are issued by GPs – a figure that has not changed since April 2023 when data was first released. Meanwhile, nurses issue just over 7% of fit notes with practice based pharmacists doing around 1.5%.
‘Fit notes sometimes issued where not necessarily appropriate’
Almost all healthcare professionals informing the research suggested fit notes could be issued ‘where it is not necessarily appropriate in some cases’.
Inadequate appointment times was one of the key reasons for this, the study found.
‘It takes two minutes to sign a sick note, and 20 minutes to explain to someone why they shouldn’t have a sick note, so you can see why they’re easily disseminated to patients,’ one nurse said.
The study also explored views from healthcare professionals on whether they would be more likely to be pressured by patients to issue a fit note than a GP.
It was widely argued that the ‘personality’ of the individual professional was a ‘more important factor in how “easily” that they would provide a fit note’.
Though several healthcare professionals, including some GPs, suggested newly eligible professionals ‘would be less likely than doctors to give a fit note inappropriately because they were newer to this role and therefore more likely to be cautious; and tended to be stricter in following guidance than a typical GP’.
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‘GPs are just as easy to persuade as nurses. I declined someone, but a GP issued it’ said one nurse.
‘Whenever I issue a fit note, I want to make sure there is a plan to follow… we can be more ruthless than GPs. We want to make sure we are doing it the way we have been told to do it.’
About the research
The research was commissioned by the Joint Work and Health Directorate, a joint unit between Department for Work and Pensions (DWP) and Department of Health and Social Care (DHSC).
It was carried out between January and July 2023 and involved focus groups and interviews with 84 healthcare professionals, 43 patients and 28 employers. It also drew on a national public survey of 2,023 participants.
