GPs were under fire again this last week.
Normally, I’m the first to admit that general practice deserves criticism when things go wrong. But this time my immediate reaction was different: GPs need defending.
The latest headlines were sparked by a survey suggesting that many GPs say they have never refused to sign a Fit Note (the modern name for a sick note) for a patient with a mental health condition.
At first glance, that sounds damning. It feeds the narrative that GPs are simply rubber-stamping time off work and driving the explosion in people out of the workforce for mental health reasons.
But that interpretation completely misses how the system actually works. And more importantly, it misunderstands the impossible position GPs have been put in.
Let’s start with the basics.
A patient can legally take seven days off work without seeing a doctor. Employers cannot ask for a Fit Note during that period. It’s called self-certification. Only after those seven days does a GP become involved.
When a GP first signs a Fit Note for a new condition, the maximum duration is one month. After that, future notes can be extended, in some cases indefinitely.
So by the time a GP is asked to sign one, the patient has already decided they need time off and often has already been off work for a week.
Now imagine the consultation that follows. A patient comes in and says: “My anxiety is getting worse. I’m struggling at work. I just need some time off.”
Of course, the GP will do what doctors are trained to do. We talk about the benefits of work for mental health. We discuss stress management, talking therapies, and support services. Sometimes medication.
But let’s say after all that, the GP says: “Sorry. I’m not giving you a Fit Note.”
What happens next?
The patient understandably pushes back. They may become upset. Occasionally, they escalate with: “If you make me go back to work, I don’t know what I might do.”
Sick notes put GPs in an impossible bind. This is what really happens when you demand one - Renee Hoenderkamp
|Getty Images
Now the doctor faces a choice.
Give a piece of paper, allowing a few weeks off or risk a distressed patient potentially harming themselves.
No caring doctor is going to gamble with that.
But the problems don’t end there. If a GP refuses, the patient can simply book with another doctor in the same practice. If they still don’t get what they want, they’ll keep trying and eventually someone signs the note. In the meantime, time and resources have been wasted across multiple appointments.
And often something worse happens: A complaint arrives.
Complaints are not a minor inconvenience for doctors. They trigger lengthy administrative processes involving practice managers, written responses, back-and-forth correspondence, and sometimes escalation to NHS England or even the GMC. They can drag on for months. For many doctors, they are one of the most stressful parts of the job.
All because a GP declined to sign a piece of paper.
And it isn’t just mental health, a FitNote is a FitNote. I remember a case from years ago.
A patient with a bad knee had already received months of Fit Notes and came to see me for another one. We had a good, constructive conversation.
She worked as a driver, but the knee pain meant she couldn’t drive. I gently suggested that since the problem had been ongoing and wasn’t improving, it might be worth thinking about a different type of job. We discussed possibilities. It felt like a helpful conversation. I still signed a one-month Fit Note, giving her time to explore options.
A few days later, the complaint arrived.
Apparently, by suggesting another role, I had implied she was lazy. That she didn’t want to work. That I had humiliated her. The complaint ran to four pages. It took weeks to resolve, sleepless nights, a written apology, and endless admin.
All because I had dared to suggest a future without Fit Notes.
Why? The heart of the issue is that GPs are the gateway to benefits. If we say no to a Fit Note, the patient may lose access to what they consider their income. That changes the entire dynamic of the consultation. The doctor is no longer just providing medical advice.
They are deciding whether someone gets paid by the state or must go to work.
That is a completely different role, and one that medicine was never designed to fulfil.
So what is the answer – its actually quite simple.
Take long-term Fit Notes away from GPs. GPs should absolutely be able to issue short-term notes for straightforward illnesses as a one-off. Flu? A bad infection? A minor injury? A one-off mental health crisis? That’s appropriate. But anything beyond that should go elsewhere.
Patients needing ongoing certification should see an independent doctor they don’t have a relationship with, whose sole job is assessing work capability. Long-term or indefinite notes should go through fit-for-work panels, reviewed regularly and face-to-face.
Specialists should certify conditions within their expertise:
- Cancer: oncologist
- Dental infections: dentist
- Orthopaedic injuries: orthopaedic teams
Not the GP.
There are plenty of things we can legitimately criticise GPs for, but this isn’t one of them. The system has been designed in a way that puts doctors in an impossible position, where refusing a Fit Note risks complaints, conflict, and potentially serious consequences for patients. When that’s the structure, the outcome should not surprise anyone.
So by all means, debate welfare policy.
Debate work capability assessments.
Debate mental health and employment.
But stop pretending that GPs are the root of the problem.
They’re just stuck in the middle of it.
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