Supporting Patient-Centred Outcomes

a shared decision making tool about work


The UK is facing a growing challenge in terms of the health of its workforce. Every year almost a million workers take sick leave of over a month in length and more than 300,000 people permanently leave their employment due to illness or injury1. The situation is becoming critical; is estimated to rise above 17 million in the coming decades, affecting more individuals’ participation in the labour market2.

A system-wide cultural shift is needed throughout the NHS and the public health system, recognising the therapeutic benefits associated with employment and identifying work as an important health outcome. Continuous engagement of patients in conversations about the relationship between their health and work will be essential in achieving this cultural shift and in helping people with long-term conditions remain in employment.


Overview of Sustainable Healthcare pilot:

Shared decision-making (SDM) takes into account both a professional’s clinical knowledge and a patient’s lived experience and facilitates a conversation as peers on a journey to find the best possible outcome for the patient as an individual. AbbVie supported Professor Debbie Cohen at Cardiff University to investigate how a new SDM tool that focused on health and work could help patients return to work and improve their management of their long-term condition. In addition, the pilot explored how primary care can utilise the fit note to its best advantage for patients. 

 Working with a wide range of stakeholders, a prototype SDM tool was developed and subsequently reviewed by experts. This was then piloted in both primary and secondary care settings in England and Wales. An e-learning module to guide clinicians in how to use the SDM tool was developed to support this pilot.


Nine GP practices trialled the SDM tool, with 32 GPs using the tool and completing the evaluation and around 390 patients going through the process. Of the GPs who
responded, 37% the tool was very useful or useful when talking to patients about work and health. Only 9% said they did not find the tool useful. Around a fifth said that the tool help them explore a patient’s confidence to return to work and the obstacles and enablers for doing so. Some of the GPs also felt that the SDM tool was a less confrontational way of having such a discussion.
More than 65% said that they wrote more ‘maybe fit’ notes or were able to complete the adjustments box on the form. Importantly, 60% of those who took part in the pilot say they will continue to use the tool with patients going forward.

 While training was given to members of the British Society of Rheumatology, there was lower engagement from secondary care and only three individuals said they were adopting the SDM tool into their practice.

Analysis of the fit notes that were written during the pilot and comparison to a baseline is ongoing.

Conclusions and Impact

The project has highlighted that the use of a simple tool (built through working with key stakeholders) and simple learning through innovative learning media, can enhance primary care practitioners understanding of work as a health outcome. It has raised the importance they give to these types of conversations and their confidence in managing them. Of importance is that it seems to suggest that the tool also supports their use of the fit note and participants were more confident to write ‘maybe fit for work’ notes.

 Nationally there have also been some important initiatives to embed work as a health outcome into medical training. First, the UK Government’ s recent document Improving lives, work, health and disability which sets out the need to enhance medical education to understand the importance of work as a health outcome and the completion of the fit note. Second, the General Medical Council has updated their Outcomes for Graduates which now states that all students must be able to take a biopsychosocial history understanding the importance of work as a health outcome and implement their findings into their management plans.

 The tool is now being developed into an app so that it can be more accessible for users, and training modules for medical schools will be developed so that undergraduates can familiarise themselves with the app and how they can fulfil the expectations set out in Outcomes for Graduates.

1. Department for Work and Pensions, A million workers off sick for more than a month, February 2014. Available: [accessed April 2018]

2. The Work Foundation, The impact of long term conditions on employment and the wider UK economy, Febr 2016. Available at: [accessed April 2018]