Trust and Sick Notes: Why GPs Say Patient Relationships Matter More Than Ever

In healthcare, few relationships matter more than the bond between a patient and their GP. Yet increasingly, that relationship is being tested by the practical demands of modern general practice, particularly around the issue of sick notes—formally known as fit notes—that GPs issue to confirm whether patients are fit to work.

A recent piece in the British Medical Journal by Dr Helen Salisbury explores this tension, highlighting how general practitioners navigate the complex territory of patient trust when issuing fit notes. The central question Salisbury poses strikes at the heart of clinical practice: if a GP doesn’t trust their patients, how can they expect patients to trust them? And without that mutual trust, can medicine really be done well?

Fit notes have been the standard tool in UK general practice since 2010, replacing the older sick note system. They represent a shift from simply confirming that a patient is unable to work, to offering a more nuanced assessment. Rather than a simple yes or no, fit notes can indicate that a patient is unfit for work, or that they may be fit for work with certain adjustments or modifications. This approach was intended to support earlier return to work and better outcomes for patients with health conditions.

In practice, however, fit notes have become a significant administrative burden for GPs. Practices report issuing them regularly—sometimes multiple times per day—and the process involves clinical judgment about a patient’s ability to perform their job, even when GPs may have limited knowledge of what that job actually entails.

The relationship between trust and effective medicine is well established in medical research. When patients trust their doctor, they are more likely to follow medical advice, disclose important health information, and engage actively in managing their health. Conversely, when trust is absent, clinical outcomes suffer. Patients may withhold information, dismiss medical advice, or seek unnecessary additional appointments elsewhere.

For GPs, the challenge with fit notes is particularly acute. A patient may request a fit note for a condition the GP considers manageable with work, creating a potential conflict. The GP must balance their clinical judgment against the patient’s own assessment of their capability. This is where the question of trust becomes paramount.

“If I don’t trust my patients, why should I expect them to trust me?” as Salisbury frames it, encapsulates a wider concern in general practice. When doctors approach consultations with suspicion—worried that patients may be exaggerating their symptoms or seeking fit notes for inappropriate reasons—the entire clinical relationship becomes strained. Patients sense this lack of trust, and it undermines their confidence in the GP’s advice and clinical recommendations.

UK general practice has been under significant strain in recent years. GPs are managing increasing workloads with limited resources, and fit note requests form part of this demand. According to NHS figures, GPs issue millions of fit notes annually, many of which require clinical time that might otherwise be spent on direct patient care.

This workload pressure can inadvertently drive a culture of suspicion. When GPs are time-pressed and facing administrative demands, they may become more sceptical of fit note requests, viewing them as bureaucratic obstacles rather than legitimate healthcare needs. This defensive posture, understandable in the context of practice pressures, nonetheless erodes the trust that effective medicine depends upon.

Research consistently demonstrates that patient-centred, trusting relationships lead to better health outcomes. Patients who feel their doctor trusts them are more likely to be honest about their symptoms and circumstances, enabling more accurate diagnosis and treatment. They are also more likely to adhere to treatment recommendations and engage in preventive care.

The inverse is also true: when patients feel judged or distrusted by their healthcare provider, they may avoid seeking care altogether or withhold important clinical information. This is particularly concerning for conditions where early intervention could prevent serious complications.

The tension around fit notes reflects a broader challenge in modern medicine: balancing clinical expertise with patient autonomy and self-knowledge. GPs are trained clinicians with responsibility for accurate medical assessment. Yet patients are experts in their own bodies and circumstances. Effective practice requires respecting both perspectives.

Salisbury’s argument suggests that the starting point for this balance must be trust. Rather than approaching a fit note request with suspicion, GPs who adopt a trusting stance may find that patients reciprocate with honesty and engagement. This doesn’t mean issuing fit notes uncritically—clinical judgment remains essential. But it means approaching the consultation with the assumption that the patient is acting in good faith, whilst retaining the ability to explore concerns if the clinical picture seems inconsistent.

The challenges around fit notes and patient trust speak to wider pressures within the NHS. General practice operates within significant resource constraints, managing an ageing population with increasingly complex health needs. In this context, maintaining the kind of trust-based relationships that good medicine requires becomes all the more difficult—and all the more important.

Restoring and protecting this trust will require attention not just to individual clinical consultations, but to the systemic pressures that make those consultations increasingly fraught. This includes adequate funding for general practice, reasonable workloads for GPs, and recognition of the time required for genuine patient-centred care.

Key Takeaways

• Trust is fundamental to effective GP-patient relationships and clinical outcomes.
• Fit notes remain an important but administratively burdensome part of general practice.
• GPs face pressure to assess fitness for work, sometimes creating tension with patient requests.
• A trusting approach to patient care, grounded in good faith assumptions, may improve both relationships and health outcomes.

What This Means for Kent Residents

If you’re a patient in Kent registered with a GP through the NHS Kent and Medway Integrated Care Board, the conversation about trust and fit notes affects you directly. When you visit your GP for a fit note, you’re entering into a relationship that ideally rests on mutual trust and respect. If you feel your GP doesn’t believe you, or you sense suspicion during your consultation, this can undermine your confidence in their clinical advice more broadly. Conversely, if your GP takes time to listen and understand your circumstances, that trust creates the foundation for better healthcare decisions. If you have concerns about how a fit note consultation went, or if you feel your symptoms haven’t been taken seriously, you can discuss this directly with your practice or contact NHS England’s patient feedback service for support and advice.