GPs' Experiences with Mental Health Fit Notes
Hundreds of general practitioners (GPs) have informed the BBC that they have never refused to sign a sick note, known as a fit note, for patients reporting mental health issues.
distributed a questionnaire to over 5,000 GPs across England, inquiring whether they had ever denied a fit note to a patient requesting one due to mental health concerns.
Out of 752 GPs who responded, 540 stated they had never refused such a request, 162 indicated they had declined at least one, and 50 preferred not to disclose their stance.
Several GPs expressed frustration with the current system, suggesting that issuing fit notes should not be part of their responsibilities.
They also recounted incidents where patients became aggressive when not signed off work. One GP described a situation where a patient refused to leave the practice without receiving a fit note.
The representativeness of the responding GPs relative to all family doctors remains uncertain.
Rising Numbers of Fit Notes Issued
The number of fit notes issued has been steadily increasing in recent years, with over 11.2 million approved by GP practices in England last year.
BBC analysis reveals this figure has grown by nearly 850,000 over the past six years.
Fit notes are issued when an individual is unwell or unable to work for more than seven days. They are not required to specify the reason for the absence, and 72% of fit notes do not include a stated cause.
However, more than 956,000 notes last year cited mental health and behavioral disorders as the primary reason, surpassing any other condition.
While GPs issue the majority of fit notes, other healthcare professionals such as nurses, pharmacists, physiotherapists, and occupational health therapists are also authorized to provide them.
Fit notes provide guidance on how a patient’s health affects their ability to work and can assist in accessing certain benefits and sick pay.
Patients may be declared "not fit for work" or "maybe fit for work" with adjustments, though most fit notes result in complete time off work.
GPs’ Perspectives on Issuing Fit Notes
The GPs who responded to the BBC questionnaire submitted hundreds of comments, with a common theme being that signing patients off work is an unfair responsibility.
"It is hard to be patient's advocate and a judge."
They discussed how the current system can strain the doctor-patient relationship. One GP stated:
"Patients come for support - not to be dismissed."
Another commented:
"GPs should not be gatekeepers of fitness to work."
Some described signing people off work as "a dirty task" and argued it is not their role to "police the sick note system."
Many doctors emphasized that they do not always grant patients the full duration requested; instead, they often issue fit notes for shorter periods.
Several GPs explained to patients that continuing to work can benefit their mental health.
There was a notable division in attitudes toward patients. Some GPs expressed unequivocal trust in patients' honesty.
However, many noted the difficulty in refusing time off for mental health complaints. One GP asked:
"Who am I to say I don't believe that someone is struggling with their mental health? It's not like a chest infection where there is definite proof of illness."
Others were more skeptical, suggesting some patients were "not genuine" or accused them of "milking the system."
Fit note data is not categorized by age, but several GPs felt younger adults were more likely to request time off. One said:
"We sign off legions of young patients with anxiety and depression who are quite clearly not ill."
Some GPs reported they would only sign a fit note if it was "medically appropriate," while others admitted it was "not worth the grief" or "the hassle" to contest patients’ requests.
Several pointed out that it is often easier and quicker to sign off a sick note than to handle complaints arising from refusal.
Some described patients becoming aggressive. One doctor said:
"They argue and fight, we end up having to give in for our own safety."
Another added:
"It would be insane to challenge the patient."
Government and Professional Responses
Last year, a government-commissioned report examining employers' roles in health and disability described fit notes as "often problematic." The Keep Britain Working review noted that GPs frequently lack the time and occupational health training to fully assess a patient’s fitness for work.
The report highlighted that the longer a patient is off sick, the less likely they are to return to work. If absent for 4-6 weeks, there is a 96% chance of return, but this drops to 50% after one year.
The Royal College of GPs (RCGP) stated that family doctors may not always be "the most appropriate professionals" to provide long-term support for patients returning to work.
RCGP chair Professor Victoria Tzortziou Brown said GPs should continue to approve fit notes for up to three weeks but expressed openness to exploring whether responsibility for longer-term fit notes should be transferred elsewhere.
The government acknowledged the need to reform the current fit note system and is testing new approaches.
A spokesperson said:
"We know that we need to do more to build a system that works for everyone."
The BBC understands that government officials are considering alternatives, including "stay in/return to work" plans developed with businesses and occupational health professionals. It is unclear whether these would reform or replace fit notes entirely.
Jaguar Land Rover (JLR) is among 60 companies collaborating with officials to explore these possibilities.
JLR has established six "centres of wellbeing" for UK employees. These centres focus on prevention, including exercise classes and NHS health checks, as well as support services such as physiotherapy, counselling, and occupational health.
Dr Richard Peters, JLR's chief medical officer, stated:
"Firms have a part to play in supporting people with health conditions in work. It's the right thing to do because if we have a healthier staff, then we have a more productive workforce."
However, concerns exist regarding the scalability of such support. Small businesses are apprehensive about upcoming statutory sick pay changes, which will require them to pay from the first day of absence.
Tina McKenzie from the Federation of Small Businesses commented:
"Proposals to make small businesses pay for a service to provide occupational health advice, as well as fit notes, would add to these costs as well as piling on extra bureaucracy."
Tom Pollard, head of policy and campaigns at the mental health charity Mind, emphasized that any move toward an alternative system must be "approached with caution" and "built around trusting and compassionate relationships."
He added:
"It is essential that people do not feel they are being forced to work when they don't feel able to."
Additional reporting by Vicki Loader and Amy Jackson.
