John Jewitt
David Anderson 2016
Fit notes
 Physical demands of work falling since the 1950s and
yet increase in sickness certification
 Most common reason for issuing notes is back pain
and increasingly mental illness
 Drs- certified in the past so patients can obtain “sick
pay or benefits”
 Therefore the fit note was developed
Making an assessment
 “Assessment” can be:
 Face-to-face consultation
 Telephone consultation
 Report from another Dr or health professional (eg
discharge letter)
 Doctors should always consider the impact of their
illness or injury on their capacity to work
 Fitness for work depends both on attributes of the
patient and on the nature of the job
Factors determining fitness for
work
• Nature and severity of health problem(s)
• Patient’s attitudes and expectations
• Physical and mental demands of job
- Such as a plumber who has knee arthritis.
• Potential for work to exacerbate illness
- such as effect of boss/ bullying.
• Safety considerations
- remember to consider travel to and from work
Health benefits of working
Department for work and pensions website:
 “Evidence shows that work has therapeutic value and
is generally good for physical and mental health and
well-being whilst long term worklessness has negative
health effects (Waddell G. and Burton A.K. 2006, Is
work good for your health and well-being?)”
Questions that may be helpful in identifying the
need and scope for job modifications
• What is your job, and what tasks does it involve?
• Are there aspects of your job that you would find
difficult or impossible because of your health
problem(s)?
• If so, are there simple ways in which your job could be
changed to overcome these difficulties?
• Is there another job that you would find easier, to
which your employer might move you while you are
recovering?
Examples of modifications that may help a patient to
return to work
 Phased return to work
 The patient could restart with reduced working hours
and build up gradually to normal levels. Working fewer
hours each day is usually preferable to fewer days each
week
 Altered hours
 Consider the time of work as well as the number of
hours a day—for example, a patient recovering from
depression may find early starts especially difficult
Amended duties
 Changes in the organisation of work might help:
 an anxious patient with reduced confidence may benefit
from working in a team rather than alone
 Changes in job content might help:
 a patient with back pain may need to avoid prolonged
sitting to reduce discomfort
 Workplace adaptation
 Changes to seating or other aspects of a work station
may be necessary to improve comfort in a patient with
back pain
Attitudes
 Attitudes to work attendance vary widely. Not all
aspects of work are pleasant, and some people may
enjoy a legitimised opportunity for absence, at least in
the short term and vice versa.
 Doctors should not collude in what they have good
reason to believe is malingering. However, they should
make due allowance for differences in patients’
attitudes
Homework: reading
See Department of Work and Pensions website (DWP):
https://www.gov.uk/government/uploads/system/uploa
ds/attachment_data/file/183249/fitnote-gpsguidance.pdf
FIT NOTES QUIZ
 1. Can I back-date a fit note?
 2. Can I issue a fit note with a future start date?
 3. My patient has two jobs, should I issue two fit
notes?
Fit note Quiz
 4. Does the patient need to return to see the Dr at
the end of the period covered by the sick note?
 5. What if I am asked for a fit note saying someone
is fit for work?
 6. If a patient may be fit for work, what parts of
the fit note do you need to complete?
Fit Notes Quiz
 7. How do you record the time period for which
your advice applies: either about being unfit for
work, or that the patient may be fit for work?
 8. How long can you issue a fit note for?
 9. Can a patient return to work before the fit note
expires?
Anxious patient
 Mrs A is a bank clerk who has been off for 4 weeks
with low mood. She forgot that her sick note ran out
that day and she is worried that her employer will be
annoyed.
 You are on a busy Friday afternoon clinic and you do
not know Mrs A. She has seen your colleague for the
last 2 times in the past 6 weeks and he is not here
today.
 He has recorded though that Mrs A may be fit to
return to work at the end of this note.
 Mrs A has a long h/o anxiety and depression as well as
several periods of sickness certification in the past 3
yrs.
video
 https://www.youtube.com/watch?v=14be0hjwhAw
Your Case Studies
 DO YOU HAVE ANY CASES THAT YOU CAN BRING
TO THIS SESSION?
A challenging case about fitness to work
A situation where you were not sure whether to issue a
fit note
We can discuss these cases and all learn from them.
Case studies - one
 A delivery driver who can’t drive
 Chris is a delivery driver for a major logistics firm.
He has just had laser eye surgery and his post-op
instructions include advice that he should not to
drive for two weeks. He comes to see you expecting
to be signed off from work.
Case studies - two
 Someone who is out of work
 John is out of work and visits you with a recent
exacerbation of multiple sclerosis (MS). His records
indicate that his MS occasionally relapses, with
periods of good health in between. He is keen to find a
job and asks about work during the consultation. He
seems despondent about his recent flare-up as he
thinks it means he won’t be able to find a new job until
he is better.
Case studies - three
 An employer can’t make changes
 Alice works for a supermarket and visits you
complaining of panic attacks. You diagnose anxiety
disorder and refer her to a local talking therapy
service.
 When you raise the issue of work, Alice says she is too
distressed to work. She thinks that her job is causing
her panic attacks and does not see how she can go
back.
Case studies - four
 Relationship issues at work
 Timi comes to see you, complaining that she does
not get on with her manager, she is feeling very
stressed and asks to be signed off work.
Questions to ask when doing a fit
note
 What is your job and what tasks does it involve?
 Are there any aspects of your job that you would find
difficult or impossible because of your health
problem?
 If so, are there simple ways in which your job could be
changed to overcome these difficulties?
 Is there another job that you would find easier, to
which your employer might move you while you are
recovering?
Case studies - five
 Sandra, a 46 year old lady has recently been diagnosed with
depression and started antidepressants 3 weeks ago. She
has had 5 days off work and now comes to see you for a sick
note. She works in payroll at the head office for a local
distribution firm. She doesn’t want anyone at work to know
about her illness and doesn’t want you to write it on the
sick note. Hew new manager is very strict on sickness
absence and she is worried about disciplinary action if she
has too much time off.
 How would you approach this?
 Shall we try a role play?
Cas3 studies - six
 46 year Mike presents requesting a new sick note for
his chronic back pain. He’s been off for the last 2 years.
You notice a letter in his records from the DWP stating
that he has been found fit for work following the work
capability assessment. He doesn’t mention that he’s
been examined.
 How do you proceed?
 Can you issue the note?
 Shall we try a role play?
JSA, ESA, IS, SSP, DLA, AA, CA and other
abbreviations!
“They’ve stopped me money Doc...”
John Jewitt
David Anderson 2016
JSA
 You can claim JSA online if you are:
 actively looking for work or working fewer than 16 hours
per week
 over 18 but below State Pension age
 living in England, Scotland or Wales
 need to attend an interview at the Jobcentre

The new jobseeker interview
JSA payments
 Weekly amounts
 18-24
 25 or over
 Couples (both over 18)
 Paid usually every 2 weeks
up to £57.90
up to £73.10
up to £114.85
Employment and Support
Allowance (ESA)
 Employment and Support Allowance provides
financial help to people who are unable to work
because of illness or disability.
 Open to employed, self-employed and unemployed.
 personalised support so that you can work if you are
able to.
 It gives access to a specially trained personal adviser
and a wide range of further services including
employment, training and condition management
support.
What you get (ESA)
 Assessment rate (same as JSA) for 13 weeks after claim.
 £ 102.15 / week if in work related activity group
 £ 109. 30 / week if in the support group
 Placement in above depends on the WCA (work
capability assessment)
 Possible enhance disability premium at £ 15.75 / week
 Severe disability premium at £ 61.85 / week
Income support
 Income Support is extra money to help people on a low
income. It’s for people who don't have to sign on as
unemployed.
 Whether you qualify or not and how much you get




depends on your circumstances
You need to be carer/ child under 5/ pregnant.
Have savings below £16k
Personal allowance and extra payments.
Such as child benefit rate ( £20.70 and £13.70)
Statutory Sick Pay (SSP)
 If you're working for an employer under a contract of
service (even if you've only just started and you have done
some work), you're entitled to Statutory Sick Pay (SSP) if
the following apply:
 you're sick for at least four days in a row (including weekends
and bank holidays and days that you do not normally work)
 you have average weekly earnings of at least £102 a week
 Average weekly earnings are worked out by using earnings
in the eight weeks before sickness began.
 The standard weekly rate for SSP is £ 88.45 a week.
Scenario 1
 44 year old man who was injured in a RTA 18 months
ago. He had fractures to his right femur, right scapula
and right forearm. He now walks with a limp and is
unable to walk distances of more than 400 metres
without severe discomfort. He previously worked as a
postman but was made unemployed 6 months ago as
he could no longer perform his job. He attends to ask
for a follow on sick note. You notice a recent letter in
his notes stating that he no longer requires sick notes
and should be considered fit for work.
Scenario 1: group work
 What benefits is he entitled to?
 What is the name of the assessment that he has been
through prior to the practice receiving the letter?
 Where might he receive support?
 Under what circumstances might you be able to write a
fit note?
Scenario 2
Jill is 20. She comes to see you because she can’t make ends
meet. Her boyfriend has just left her, they used to share
a flat with their 2 year old daughter. Her boyfriend was
the bread winner and Jill is in full time education at the
local university studying nursing. She is using her
savings but only has £1000 left and fears she will have to
give up her course.
Scenario 2: group work
 What benefit might Jill be entitled to and what do you
know about it?
 Where might she be able to get some support?
 How much savings is Jill entitled to have before she
would not be able to get this benefit?
 Would she be entitled to JSA or ESA in addition?
Scenario 3
 Sally is a 40 year old who has been working in I.T. for
the last 3 weeks. She was previously unemployed after
completing a degree in computing 2 years ago. She’s
just been discharged from hospital after she had and
emergency laparoscopic cholecystectomy 3 days ago.
She left hospital without discharge information. She is
requesting a fit note as she is worried that she will not
be entitled to any money and has bills to pay. You don’t
feel that she is fit to work.
Scenario 3: group work
 What are you going to do?
 What benefit might Sally be entitled to and what do
you know about it?
 Who is responsible for paying the benefit?
Disability Living Allowance
 Disability Living Allowance (DLA) is a tax-free benefit
for disabled children and adults to help with extra
costs they may have because they’re disabled.
DLA- who is entitled?
 You may get Disability Living Allowance if:
 you have a physical or mental disability, or both
 your disability is severe enough for you to need help
caring for yourself or you have walking difficulties, or
both
 you are under 65 when you claim
 You can get Disability Living Allowance whether or not
you work.
 It isn't usually affected by any savings or income.
 Amount received is based on current needs and
circumstances
DLA
 Disability Living Allowance has two parts called
'components':
 a care component - if you need help looking after
yourself or supervision to keep safe
 a mobility component - if you can't walk or need help
getting around
 Some people will be entitled to get just one
component; others may get both.
 Paid at different rates depending on how your
disability affects you.
DLA payments




Care component
Lowest = £ 21.80 – help for some of the day/ meals etc
Middle = £ 55.10 – freq help or constant supervision
Highest = £ 83.20 – supervision/ help day and night.
 Mobility component
 Lower = £ 21.80 – needs guidance / supervision
outdoors
 Higher = £ 57.45 – other, more severe, walking
difficulty
DLA
 DS1500
 Special rules - if you're terminally ill



If you have a progressive disease and are not expected
to live for more than another six months there are
special rules.
Get benefit more quickly and easily.
Highest care component = £ 82.30 weekly
Proposed changes to Disability
Living Allowance (DLA)
 The government wants to replace DLA with Personal
Independence Payment to support disabled people with
the greatest needs and help them live more independently.
 What the change means
 Between 2013 and 2016 everyone aged 16 to 64 receiving
DLA will be reassessed to see whether they are entitled to
the new Personal Independence Payment.
 People entitled to Personal Independence Payment will
have their claims transferred over and their DLA will stop.
 Those not found to be entitled to Personal Independence
Payment will be informed and their DLA will stop. They
may be able to claim other benefits.
Personal Independence Payment
 Disability Living Allowance (DLA) has been fully
replaced by Personal Independence Payment (PIP) for
people aged 16 to 64 from 10 June 2013 for new claims
only.
Personal Independence Payment
What is PIP?
 PIP is to help towards some of the extra costs arising
from a health condition or disability. It is based on how
a person’s condition affects them, not the condition
they have.
 Can get from £ 21.80 - £ 139.75 a week depending on
how the condition affects you, not the condition itself.
Personal Independence Payment
Who is eligible?
 PIP is for people aged 16 to 64
 DLA remains for children up to the age of 16.From
October 2013, the Department forWork and Pensions
(DWP) will contact them as they approach 16 to
explain what will happen
 DLA remains available to existing claimants who were
aged 65 or over on 8 April 2013 (the day that PIP was
introduced).
Key facts I
 In the same way as DLA, claimants can receive PIP
whether they are in or out of work.
 The benefit is not means tested or taxed.
There are two components to PIP:
– for daily living
- and mobility needs.
Each component can be paid at standard rate, or
enhanced rate for those with the greatest needs.
May require a face-to-face assessment as part of claim.
Key facts II
Subject to regular review.
Payment calculated through a points system for each
component:
 Daily Living
Mobility
Between Oct 2013-2015, all current claimants of DLA
between ages of 16-64 will be re-assessed.
Further reading:
http://www.dwp.gov.uk/publications/specialistguides/pip-toolkit/
Attendance Allowance
 Attendance Allowance is a tax-free benefit. You may
get Attendance Allowance if you're aged 65 or over and
need help with personal care because you're physically
or mentally disabled.
 Basically.....
 DLA for the over 65s
You can get £ 55.10 to £ 82.30 a week.
Who can get Attendance
Allowance?
 You may get AA if the following apply:
 you have a physical disability, a mental disability or both
 your disability is severe enough for you to need help caring for
yourself or someone to supervise you, for your own or
someone else’s safety
 you are aged 65 or over when you claim – compare with DLA
 Attendance Allowance isn't usually affected by any savings or
income you may have.
 Special rules apply
 Occasionally a medical examination is required to assess
how the conditions affects you.
Benefits
 There are loads more!
 You don’t really need to know about them all


...but you do need to know a man that does!
...or some resources to signpost to.
Where can patients get help?
 Direct patients to the benefits adviser service- an
online service where they can get help and advice
about benefits entitlement and comparisons of
financial impact of change of roles.
 Citizen’s advice
Other benefits?
 Other benefits/income that you may like to know about include:
Carer’s allowance
Council tax benefit
Housing benefit
Child maintainence
Statutory maternity pay
Maternity allowance
Bereavement payments
Funeral payments
? State pension
 Check out www.direct.gov.uk