In April the old sick note, which had survived in its current form since 1922,1 was finally replaced with the new fit note. The aim is to encourage patients to return to work sooner, by focussing on capability rather than disability, while at the same time simplifying the system and reducing the number of forms that GPs need to complete.

In 2007, 172 million working days were lost through sickness absence, which equates to seven days for each working person. There are 2.6 million people, representing 7% of the workforce, receiving incapacity benefit2 and the cost to the economy from sickness absence and worklessness is more than £100 billion a year.1

Moreover, prolonged sickness absence is detrimental to both physical and mental health. Work provides material and psychosocial needs, and confers a sense of identity and social status. There is strong evidence that unemployment leads to poorer physical and mental health, with an increase in overall mortality, cardiovascular mortality and suicide.3

The new fit note recognises the flexibility of the modern workplace and is designed to improve communication between GPs and employers. It includes a new option: ‘you may be fit for work taking account of the following advice,' four tick boxes indicating strategies which are commonly used to facilitate a return to work, and an enlarged comments section in which to provide details of functional limitations and possible solutions.

There are a number of benefits for GPs. The archaic requirement for face-to-face consultations has been dropped, forms Med3 and Med5 have been amalgamated, form Med4 has been withdrawn, and the removal of the ‘fit for work' option should help expose the myth that patients need to be ‘signed back' to work. Patients will also benefit from recognition of the convenience of telephone consultations and from empowerment to make their own informed decisions about when to return to work.

Mental health disorders are the most common reason for sickness certification4 and account for almost 40% of sickness absence.5 From 1996 to 2006, the proportion of incapacity benefit claimants with mental health problems increased sharply from 26% to 41%.1

It is therefore surprising that there is a lack of evidence regarding the impact of returning to work on people with mild/moderate mental health problems.3 Nevertheless, it can be argued that work promotes psychological wellbeing, for example by enabling personal growth and providing a sense of purpose, and in this way facilitates full recovery from depression.6

There is a problem, however, when work itself is the cause of the illness. Work stress results from high demands coupled to lack of control and lack of support.7 In susceptible individuals this can lead to burnout, with the risk of depression and/or substance misuse. Making unreasonable demands, denying control and constantly criticising constitutes workplace bullying.8 Data from the Dunedin study shows that high psychological work demands double the risk of major depression.9

The other major cause of sickness absence is musculoskeletal disorders, which account for 15% of the total number of days certified5 and 17% of those on incapacity benefit.1 These patients are often unable to access timely interventions, because of excessive waiting times for physiotherapy or the absence of good occupational health services - only 12% of the working population have access to an occupational health physician.10 A recent study found that an integrated care programme for patients with persistent low back pain (supervised by an occupational health physician and comprising a workplace intervention and graded activity programme) reduced the median duration of work absence from 208 to 88 days.11

In conclusion, the new fit note is a welcome improvement on its predecessor. I doubt, however, that by itself it will achieve a significant reduction in sickness absence. To do that, we need to address the issues of workplace bullying, rapid access to treatment and the inadequate provision of occupational health services.