title: Recommendations to facilitate the ideal fit note: are they achievable in practice?
abstract: BACKGROUND
  Although the UK fit note has been broadly welcomed as a tool to facilitate return to work, difficulties and uncertainties have resulted in wide variation in its use. Agreement on what constitutes the 'ideal' fit note from the perspective of all stakeholders is needed to inform best practice. A recent Delphi study conducted by the authors reached consensus on 67 recommendations for best practice in fit note use for employed patients. However, such recommendations are not necessarily followed in practice. The purpose of this study was therefore to investigate the perceived achievability of implementing these Delphi recommendations with a further reference panel of stakeholders.
  
  
  METHODS
  Potential participants were identified by the research team and study steering group. These included representatives of employers, government departments, trades unions, patient organisations, general and medical practitioners and occupational health organisations who were believed to have the knowledge and experience to comment on the recommendations. The consensus Delphi statements were presented to the participants on-line. Participants were invited to comment on whether the recommendations were achievable, and what might hinder or facilitate their use in practice. Free text comments were combined with comments made in the Delphi study that referred to issues of feasibility or practicality. These were synthesised and analysed thematically.
  
  
  RESULTS
  Twelve individuals representing a range of stakeholder groups participated. Many of the recommendations were considered achievable, such as improved format and use of the electronic fit note, completion of all fields, better application and revision of guidance and education in fit note use. However a number of obstacles to implementation were identified. These included: legislation governing the fit note and GP contracts; the costs and complexity of IT systems and software; the limitations of the GP consultation; unclear roles and responsibilities for the funding and delivery of education, guidance and training for all stakeholders, and the evaluation of practice.
  
  
  CONCLUSIONS
  This study demonstrated that although many recommendations for the ideal fit note are considered achievable, there are considerable financial, legal, organisational and professional obstacles to be overcome in order for the recommendations to be implemented successfully.
authors.affiliation: School of Health Sciences, University of Nottingham,, A Floor, Medical School, Queens Medical Centre, Nottingham, NG7 2HA, UK. Carolyn.coole@nottingham.ac.uk.
authors.forename: Carol
authors.initials: C
authors.lastname: Coole
authors.affiliation: School of Health Sciences, University of Nottingham,, A Floor, Medical School, Queens Medical Centre, Nottingham, NG7 2HA, UK. Fiona.nouri@nottingham.ac.uk.
authors.forename: Fiona
authors.initials: F
authors.lastname: Nouri
authors.affiliation: Research Design Service for East Midlands, School of Medicine, C Floor, Room 2400, Queen's Medical Centre, Nottingham, NG7 2UH, UK. Iskra.potgieter@nottingham.ac.uk.
authors.forename: Iskra
authors.initials: I
authors.lastname: Potgieter
authors.affiliation: New Academic Unit, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK. Pjw25@leicester.ac.uk.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Watson
authors.affiliation: Institute of Mental Health, Jubilee Campus, Room D16, Wollaton Road, Nottingham, NG8 1BB, UK. Louise.thomson@nottingham.ac.uk.
authors.forename: Louise
authors.initials: L
authors.lastname: Thomson
authors.affiliation: Inclusion Healthcare, Charles Berry House, 45 East Bond Street, Leicester, LE1 4SX, UK. robhampton@doctors.org.uk.
authors.forename: Rob
authors.initials: R
authors.lastname: Hampton
authors.affiliation: School of Health Sciences, University of Nottingham,, A Floor, Medical School, Queens Medical Centre, Nottingham, NG7 2HA, UK. Avril.drummond@nottingham.ac.uk.
authors.forename: Avril
authors.initials: A
authors.lastname: Drummond
mesh_terms: D003697:Delphi Technique; D004185:Disability Evaluation; D004651:Employment / Q000592:standards; D058006:General Practice / Q000592:standards; D006801:Humans; D062707:Return to Work