- Faculty of Occupational Medicine - https://www.fom.ac.uk -

Competency 2 – Good Clinical Care: Understand the process of rehabilitation

Objective: to understand and manage the legal and ethical implications of advice on suitability for work


Know the basis of the UK sickness certification scheme

A certificate commonly referred to as a ‘fit note’ is a medical statement that records the advice given by the doctor to the patient regarding their ability to perform their own or usual type of occupation.

It is an official legal document that may be used by a patient as evidence to support a claim for:

For the first 7 days of any illness an employed claimant completes a ‘self-certificate’ or SC2. An employee only requires a medical certificate from their doctor after the first 7 days of absence. If one is requested within the first 7 days, a doctor can provide a private medical certificate for which there is a charge.

Know when and how certificates should be issued

Fit note: guidance for patients and employees [1]

Social security regulations state that only a registered medical practitioner can issue statements of a person’s incapacity for work. Hence a certificate may be filled in by a GP or hospital doctor for periods of incapacity to work likely to be more than 7 days. The duty to provide a certificate note rests with the doctor who has clinical responsibility for the patient at the time. Hospitals are required to provide all certificates for social security and Statutory Sick Pay purposes for both in-patients and outpatients who are incapable of work (see below).

Key points

It is important when advising a patient about fitness for work to consider:

There are rules that govern the completion of certificates:

Certification should be viewed as important as writing a prescription.

When used appropriately, certification of a period of time away from work and then a considered return with adjustments if needed, can support a patient’s recovery and rehabilitation. Return to work is one of the key clinical outcomes of successful clinical treatment.

The Details
The fit note has options that initially are: you are not fit for work; or you may be fit for work taking account of the following advice.

There are then tick boxes for the advice which are:

The Fit note also has an area for comments from the signing practitioner. This box must be completed if “may be fit for work” has been ticked and may be useful to complete if “not fit for work” has been indicated

Understand the impact of certification on work

Waddell G and Burton AK, Concepts of Rehabilitation for the Management of Common Health Complaints [2]. 2004, London: TSO.

Waddell G and Burton AK, Is work good for your health and well being [3]? 2006, London: TSO.

Concepts Of Rehabilitation For The Management Of Common Health Problems: Evidence Base [4] (Appendices)

It is important to consider carefully whether advising a patient to abstain from work is the most appropriate clinical management. A doctor’s advice is important in shaping patients’ and employers’ beliefs about work and health and can influence a patient’s ability to return to work.

Inappropriate certification can lead to a risk in:

There is now strong evidence base that work is generally good for physical and mental health and well-being. Worklessness is associated with poorer physical and mental health. Work can be therapeutic and reverses adverse effects of unemployment in the majority of healthy people of working age as well as disabled individuals. However it is important to take into account the nature and quality of work and its social context; jobs should be safe and accommodating. On overall balance the benefits of working outweigh its risks and the harmful effects of long-term unemployment or prolonged sickness absence.

Understand the process of rehabilitation in the context of return to work and the support services available

Equality and Human Rights Commission [5]

Disability Rights [6]

Rehabilitation: an integral part of clinical practice [7] by A. Frank & M. Chamberlain. Occupational Medicine vol 56 no.5:289-290.

Rehabilitation in occupational health terms relates to returning an individual to some type of work or social inclusion. If an individual is in work this might mean seeking suitable alterations to their job or redeployment. This could include temporary or permanent alterations depending on the medical condition and the job they do.

For example a shift worker who has recently been diagnosed with diabetes and started on medication wants to return to work after a spell of absence. In order to ensure adequate management of his diabetes it is important to take regular meals and medication at the correct and regular times. This is difficult to achieve with recently diagnosed diabetes on shift work, as their meal times/activity levels are variable depending on what shift they are on, so one recommendation that would be advisable as part of a rehabilitation programme would be to abstain from shift work for a period of time until reviewed by their practitioner and their diabetes has been adequately controlled.

Rehabilitation has traditionally been a separate, second stage process carried out after medical treatment has no more to offer. However, research shows that obstacles to recovery are often predominantly psychosocial in nature rather than just relating to pathology. Rehabilitation must therefore focus on identifying and overcoming the numerous factors that prevent an individual from recovery and returning to work. Rehabilitation needs to be considered early on in the management of a patient and not as an add-on process at the end of a period of treatment.

It is not always essential for an individual to be 100% fit to be able to return to work. It is important to consider work-related factors, employer attitudes, process and practice.

Returning to work in any capacity can be very therapeutic and an essential part of rehabilitation. Therefore consider the nature of the medical condition and functional limitations, when suggesting work adjustments to enable an early return to work.

Consider carrying out the following:

ActThe Equality Act 2010, which now emcompasses disability discrimination [8]

https://www.gov.uk/browse/disabilities [9]

There are some medical conditions which may be covered by the disability component of the Equality Act (EA). Under this act an employer is legally required to consider ‘reasonable adjustments’ to the workplace. In order to qualify under the EA the individual must have ‘a mental or physical impairment that has an adverse effect on their ability to carry out normal daily activities, and that the adverse effect is substantial and long-term’.

Reasonable workplace adjustments in such situations include such things as:

There are many support services available for people who are deemed to be protected under the EA. Some are listed below:

Jobcentre Plus [10] www.jobcentreplus.gov.uk

Work Coaches [11] found in Jobcentre Plus

Access to work [12], a scheme available through Jobcentre Plus