Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Sick notes and a national illness service

BMJ 2024; 385 doi: (Published 23 April 2024) Cite this as: BMJ 2024;385:q918
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on X @HelenRSalisbury

A common complaint about the NHS is that it’s not so much a health service as an illness service and that we’d be a healthier, happier, and richer society if we focused on prevention rather than leaping into action only when people fall ill. There are many analogies, such as not just fishing bodies out of the river but going upstream to find out who’s pushing people in, or building a fence at the top of the cliff rather than parking your ambulance at the bottom.

Of course, the NHS has some effective prevention programmes, including immunisations and the screening programmes for bowel and cervical cancer. The NHS Health Check is an attempt to find people who would benefit from specific interventions to prevent strokes and heart attacks.

However, only 10-20% of health is attributable to healthcare.12 With the honourable exception of our colleagues in public health, most doctors are downstream or in that ambulance, trained to treat the sick, fix the broken, and ease suffering when we can’t cure. It’s the government’s job to tackle the wider causes of ill health. The news of legislation currently in the Houses of Parliament aimed at creating a smokefree generation, potentially avoiding 75 000 deaths a year, is very welcome.34 But those in power really need to look at the other socially determined causes of ill health and early death. Poor housing, alcohol, obesity, and poverty are all high on the list, and the climate crisis may soon overshadow them all.

As a GP I do what I can to control blood pressure, offer smoking cessation advice, and encourage my patients to adopt a healthy lifestyle. I can refer patients to a social prescriber for support with housing or offer food bank vouchers, but this isn’t an adequate response to the need. The NHS is struggling to perform its job as a treatment service, and it really doesn’t have the capacity or the tools to be a prevention service too. That power and responsibility lies with the government.

In the face of the current public health crisis, with life expectancy stalling and record numbers of people absent from the workforce through ill health, we might hope for leaders who look seriously at causes and remedies.56 They could consider what fiscal levers are available to make healthy food cheaper than chips or how to reduce alcohol consumption. Enabling the provision of decent public housing and reining in exploitative landlords would help.

Instead, we have another pronouncement on sick notes (officially, “fit notes”). As too many people are signed off sick, the government intends to take this duty away from doctors—from the people who know the patients, the illness, and the treatments—and hand the task to as yet unspecified others, whose role it seems will be to “support” people to help them return to work, taking away their welfare benefits if this fails.7

This punitive approach won’t help either the individuals or the nation. Luckily, Rishi Sunak’s proposals relate to a putative next term of government, not the current one, so we can hope that they’re just political signals rather than serious plans.