How Britain’s sick note culture made us the West’s most workshy nation

It’s not an honour to which any nation would aspire but Britain can now boast of being the sick-note capital of the West.

The UK is the only G7 nation where economic inertia is higher than it was before the pandemic; a spiralling system in which numbers of working-age adults neither in a job nor looking for one is fast-rising.

A staggering 11 million absence notes were issued over the past year – up a fifth, compared to 2021. And the Prime Minister, Rishi Sunak, has now highlighted the issue, pledging to end Britain’s “sick note culture”, which he described on Friday as having “wiped out a decade’s worth of progress”.

Almost 9.5 million adults were out of work in January – the highest figure since 2011 - something the prime minister ascribed, in part, to benefits becoming a “lifestyle choice” for some.

As such, the Government plans to “tighten up” assessments for those deemed unfit to work, transferring the responsibility for writing sick notes – or fit notes as they are officially called – from GPs to as-yet-undefined “specialist work and health professionals”.

Doctors were officially tasked with signing off the unwell in 1944, with a system of sickness benefits, paid via National Insurance, set up two years later.

The system was designed to keep employees well, and provide a safety net for them to return to work, but faced criticism almost immediately by doctors, who  expressed frustration at the extra bureaucracy. In the early 1980s, as part of efforts to relieve some of this burden, the law was changed so that employees were only required to obtain a sick note if they were absent for more than a week.

At the same time, the apparent overuse of sick notes began permeating mainstream culture; the moniker was given to the protagonist of ITV drama London’s Burning – Bert “Sicknote” Quigley – and cartoons that mocked signed-off hypochondriacs appeared in newspapers.

In the early Nineties, the term spread to the back pages, with “Sicknote” deemed a fitting nickname for a litany of football players, most prominently the England international, Darren Anderton, who were plagued by injuries.

The Government attempted a £45 million overhaul to the system in 2010, which included the rebranding of sick notes as “fit notes” in an effort to encourage doctors to focus on what work a patient could do as well as what they couldn’t (although the name has never managed to stick.) Still, nothing has seemed able to stop long-term sickness becoming the main driver of economic inactivity in Britain.

Dr Eva Patel, a GP in Barnet, Herts, attributes the rise in sick notes to the “current welfare system and benefits and the easiness of getting a sick note from a doctor”. Being overworked themselves – a report from the British Medical Association last year found that a quarter of all doctors were at “high risk of burnout” – is creating further issues, she adds.

While the Government has raised concerns that many sick notes are being reissued without appropriate assessment, GPs do “not have enough capacity or time in the working day to spend 10-15 minutes per patient requiring a long-term/extension of sick note. We need to prioritise acutely sick patients,” says Dr Patel. At her practice, a telephone check-in or face-to-face consultation is given, with subsequent checks sometimes moving online.

‘GPs have very little ability to say no’

But pushing for an end to “sick note culture” while 7.5 million people are on NHS waiting lists is simply not realistic, explains Dr Edward Pooley, a GP in Nottingham. “People are currently waiting between nine and 12 months for a hospital appointment and that carries a lot of sickness and illness, and sick note use,” he says. “If we get people seen quicker by hospitals, and operated on or seen by the right person, then they can get back to work quicker.”

The two issues that have contributed most to the rise in sick-note requests at his surgery are mental health complaints – antidepressants are now taken by a record 8.6 million adults in England, a figure that has almost doubled since 2011 – and musculoskeletal issues, such as back pain. Remote working may in part be to blame for the latter, according to figures from the Office for National Statistics, with poor home ergonomics leading to reports of growing chronic pain since the first lockdown. (Long Covid, too, has been cited as another driver of long-term illness figures.)

“The majority of sick notes I issue are [for] people who actually do want to work,” Dr Pooley says. Inevitably, though, there are a number who don’t. But two factors discourage GPs from challenging such patients. Either patients complain – leading to an appeals process, and more paperwork for GPs. Or refusing to sign them off means their statutory pay or benefit will be removed, leading to financial instability, and in many cases worsening the issue they were given leave for in the first place.

Dr Jeff Foster, a GP in Warwickshire, adds that “it is not the job of a GP to act as the ‘sick police’ to try to catch people out and see if they are genuinely worthy of their sick note. We have a government-run system in place, where occupational health teams are specifically trained and employed to assess patients who are long-term sick and see if they should be going back to work and in what capacity.”

Many companies employ the Bradford Factor – a formula that measures employees’ annual absences. But this can be a blunt tool, if not a counterproductive one: one psychologist explains that many of her clients end up taking longer leave than required, because doing so for one day “is going to count as ‘one absence’, so they might as well take the rest of the week off,” as this is often recorded in the same way.

Given current polling suggests the Conservatives are highly likely to struggle at the next election (and therefore unable to get any of these reforms through), and Labour has called the Prime Minister’s announcement a sign he has “run out of ideas,” meaningful change to the system may not be coming anytime soon.

But for whomever is in power, it isn’t a problem that can long be ignored.

In the short term, Dr Pooley suggests the introduction of time limits on GPs’ sick notes – perhaps up to “a maximum of one month”, with anything further requiring a hospital specialist’s sign-off, as a means of stemming the tide.

But expecting people to return to work after an extended absence without any kind of infrastructure in place is unlikely to fix the fundamental problems, he says. “There’s no support to stop people being on sick notes. Just taking them away doesn’t really help – it just puts people into more of a cycle of despair and illness.”

Gemma Bullivant, an HR consultant and executive coach, believes current company culture is a key cause of Britain’s ailing state. She has seen a rise in clients claiming to have high levels of stress, triggered by a “fast pace of work, perceived inability to say no, lack of control or autonomy, vast amounts of information to consume and process, an inability to switch off and an ‘always on’ culture.”

On Friday, the Government opened a Call for Evidence for people to submit their experiences of sick leave. But among medical professionals at least, there is little optimism – not least because sick notes are about so much more than sick notes. Dealing with them in isolation, Dr Pooley says, “probably won’t help GPs at all”. Nor those they are meant to be helping in the first place.

Iain Duncan Smith, the former secretary of state for work and pensions who was in charge when the last overhaul took place, takes the opposite view, however. He calls Rishi Sunak’s plans “the right move to make … It’s about doing the right thing.”