Fit note reform what the Keep Britain Working review means for UK employers

What is wrong with the current fit note system?

Around 11 million fit notes are issued in England every year ⁽¹⁾. More than 90% of these declare the individual not fit for work ⁽²⁾. Add to those facts that only 6 in 10 employers consider the current process ineffective at supporting employees’ work and health needs ⁽²⁾ and only 29% of primary care staff see issuing fit notes as a good use of GP time ⁽²⁾ and it’s clear a reform is needed.

The fit note was introduced in 2010 to replace the old sick note. It included a may be fit for work option intended to encourage adjustments and phased returns. In practice, only 7% of fit notes use this option ⁽²⁾ and clinicians often lack the time or occupational context to explore workplace adjustments in a ten minute appointment and they typically do not know the specific demands of a patient’s role so the system defaults to not fit for work.

Three consistent employer concerns emerged from the Government’s Call for Evidence ⁽²⁾:

Fit notes lack useful information about what the employee can do, what adjustments might help and how long limitations may last.
Fit notes are disconnected from occupational health, vocational rehabilitation and employment support.
Fit notes are increasingly issued without face-to-face consultation, often by clinicians with limited knowledge of the job role.

Since July 2022, nurses, occupational therapists, pharmacists and physiotherapists have been able to certify fit notes where the condition falls within their scope ⁽³⁾. This expanded the clinical base but did not solve the structural problem of what information a fit note contains.

What is changing under the Keep Britain Working fit note reform?

The Keep Britain Working fit note reform replaces the current model with personalised Stay in Work and Return to Work plans ⁽⁴⁾. These plans are supported by 3-way conversations between the employee, employer and a trained work and health professionals.

Four pilot areas began testing this approach in July 2026, backed by three million pounds in the first year and covering up to one hundred thousand appointments ⁽⁴⁾. If the pilots demonstrate the model works, the Government has committed to bringing forward legislation to reform the system nationally.

The four pilot areas are:

Birmingham and Solihull
Coventry and Warwickshire
Cornwall and the Isles of Scilly
Lancashire and South Cumbria

Two models are being tested ⁽⁴⁾:

In Birmingham and Solihull and Coventry and Warwickshire, GPs issue an initial fit note and then refer patients to a new support service staffed by clinical and non-clinical professionals.
In Cornwall and the Isles of Scilly and Lancashire and South Cumbria, GPs refer patients directly to support services without issuing a fit note at all.

All the models shift the emphasis from certifying incapacity to early, structured engagement around what would help the employee stay in or return to work. This includes adjustments, phased returns and keeping employees connected to their workplace from the first day of absence.

This is a material change in what is expected of employers. The current model places most of the burden of return-to-work planning after the fit note has been received whereas the new model anticipates employer engagement earlier, as part of a support pathway rather than a response to it.

Separately, the WorkWell programme is expanding nationally. More than two hundred 35 million pounds has been allocated across English regions to support up to 250,000 people with a disability or health condition to get into or stay in work ⁽⁵⁾.

What should employers do now in response to fit note reform?

The pilots do not change existing employer obligations immediately outside these areas. But they signal clearly where national policy is heading.

These are the steps that matter most:

Use the ‘be fit for work’ option actively. If a fit note includes an adjustment recommendation, employers are expected to explore whether those adjustments are feasible ⁽²⁾.
Know who can certify fit notes. Nurses, occupational therapists, pharmacists and physiotherapists can issue them ⁽³⁾.
Review return to work and absence management processes. The new model expects employers to participate in early structured conversations ⁽⁴⁾.
Integrate occupational health earlier. Limited OH integration was identified as a core failure of the current system ⁽²⁾.
Explore Vanguard Phase eligibility. 150 organisations employing 1.5 million people have signed up to the 2026 to 2029 Vanguard Phase ⁽⁴⁾.
Do not wait for legislation. The Government has signalled its intention to legislate following the pilots ⁽⁴⁾.

Why the occupational health connection is central to what comes next

Fit note reform sits alongside day one statutory sick pay, which came into effect on 6 April 2026 under the Employment Rights Act 2025 ⁽⁶⁾. Every absence episode now carries a direct payroll cost from the first day.

It also sits against a backdrop of148.8 million working days lost to sickness in 2025 (7). The average employee took nine point four sick days, a fifteen year high ⁽⁸⁾.

In Q3 of 2025 to 2026, 2.85 million fit notes were issued in England. 42.3% were for periods of five weeks or longer ⁽⁹⁾. Mental ill health remains the leading driver of long term sickness absence, cited by 41% of employers ⁽⁸⁾.

The reform assumes employers can respond to earlier clinical contact. When a work and health coach contacts an employer in week one of absence, the employer needs the processes, the OH pathway and the line manager capability to engage constructively. Employers without integrated workplace health provision will find this harder to meet.

How Square Health helps employers prepare

Square Health provides integrated workplace health and absence management infrastructure that positions UK employers to operate within the reformed model, not react to it.

Our occupational health provision connects clinical access, case management and return to work planning. It does not sit as a standalone referral route activated only once absence becomes complex.

If your organisation is reviewing its approach to absence, occupational health or return to work processes in light of the reform, speak to the Square Health team.