Dr Reva Gudi is GP and healthcare leader in Hayes, Middlesex, she is also a former Conservative parliamentary candidate, and serves as a local school governor and charity trustee.
Britain’s welfare bill is enormous. Across politics, there is agreement that something must change if the system is to remain a discerning and sustainable true safety net.
From where I sit, as a GP, part of the debate is being missed.
Toughness is not the same as effectiveness.
We can tighten eligibility, redesign assessments, and change who signs people off work. But none of that answers the question I face regularly: how do we accurately determine whether somebody can work, and if they can, who builds the route back?
Early in my career, I spent consultations encouraging patients back to work. A senior colleague pointed out that the longer someone remained off work the less likely they were to return-an observation backed by evidence, and the system did little to help. I wasn’t wrong to try then, and I don’t think I’m wrong now. But there are limits to what a GP consultation can achieve. GPs are accused of handing out fit notes too easily; the more honest charge is that we are handed a blunt instrument and asked to make fine balanced judgements with it.
I recently saw a woman asking to be signed off with a condition that did not obviously prevent her from working. As I listened, another reason emerged: three young children and a struggle to manage work alongside caring for them. I understood her predicament. But childcare is not an illness.
There, in one consultation, is a weakness in the system. Social and economic problems arrive at the GP’s door requiring a medical solution. The available mechanism is a fit note, and the judgement falls to the GP. A welfare system loses credibility when ordinary pressures of life are sometimes converted into medical incapacity. Yet refusing a fit note does not make those pressures disappear.
Then there is the opposite problem: asking doctors to make judgements medicine cannot reliably make. Take PIP. PIP is not an out -of -work benefit and GPs do not decide entitlement. But the evidence we’re sometimes asked to provide illustrates a wider issue: asking clinicians for evidence about function they haven’t observed. Can the patient wash, dress, prepare food, communicate with others? These are primarily judgements about function, not straightforward clinical questions. I may see that person a handful of times a year. I can record that a patient says they struggle to dress. I cannot honestly say I’ve watched them dress, cook, travel, or interact outside my surgery. My response on the form will reflect that. With mental illness in particular, a short consultation doesn’t reliably tell me how someone functions across an ordinary day.
I can provide a diagnosis and describe what I’ve observed clinically, but there is a point at which evidence ends and assumption begins. Nor does a face-to-face assessment necessarily solve the problem. What determines incapacity cannot always be observed in an assessment room.
One response is to move these assessments away from GPs. There is merit in that; freeing clinical time would help. But changing who holds the form doesn’t necessarily answer the questions on it. The risk is that we simply transfer some of the same difficulties to another assessor. Any reform needs to recognise and mitigate that risk rather than move it elsewhere.
Even a comprehensive assessment answers only half the question. Suppose I think a patient could return to work. Return to what? I can make recommendations, but what happens when their employer can’t accommodate it? Large organisations may have occupational health: many smaller employers do not. Whatever the answer, it cannot be to place the burden on employers who have no more capacity than I do. Too often, the patient returns to my consulting room, and the only lever left is another fit note.
A patient unable to stand for eight hours may be perfectly capable of working for four. The space between not fit and fully fit is where many patients sit. Yet it is precisely the space our system struggles to manage.
GPs can describe the medical problem. We cannot create alternative duties, provide occupational health where none exists, or compel an employer to offer a phased return. Those assessing function should have the expertise to do so and where somebody is capable of some work, there needs to be a practical route back.
After years in general practice, I am convinced we ask too much of the GP consultation -to turn social problems into medical judgements, clinical information into assessments of daily function, and a fit note into a verdict on employment that we are not equipped to make.
This is not an argument for a particular welfare policy. It is a narrower point. Any reform that doesn’t reckon with what happens inside that consultation will run into the same wall.
It is crucial that we support those who genuinely need the state’s support. Equally the welfare bill matters, and so does fairness to the taxpayer.
The gap I see from my consulting room runs through the whole process, recognising what is really keeping someone from work, accurately assessing what they can do and, where they can work, creating a practical route back. But that route must also make economic sense. The calculation between what the welfare state provides, what work pays and the costs of returning to work cannot be ignored. None of this is straightforward. But addressing it piecemeal, means little changes.
Address them together, and real change becomes possible.
Dr Reva Gudi is GP and healthcare leader in Hayes, Middlesex, she is also a former Conservative parliamentary candidate, and serves as a local school governor and charity trustee.
Britain’s welfare bill is enormous. Across politics, there is agreement that something must change if the system is to remain a discerning and sustainable true safety net.
From where I sit, as a GP, part of the debate is being missed.
Toughness is not the same as effectiveness.
We can tighten eligibility, redesign assessments, and change who signs people off work. But none of that answers the question I face regularly: how do we accurately determine whether somebody can work, and if they can, who builds the route back?
Early in my career, I spent consultations encouraging patients back to work. A senior colleague pointed out that the longer someone remained off work the less likely they were to return-an observation backed by evidence, and the system did little to help. I wasn’t wrong to try then, and I don’t think I’m wrong now. But there are limits to what a GP consultation can achieve. GPs are accused of handing out fit notes too easily; the more honest charge is that we are handed a blunt instrument and asked to make fine balanced judgements with it.
I recently saw a woman asking to be signed off with a condition that did not obviously prevent her from working. As I listened, another reason emerged: three young children and a struggle to manage work alongside caring for them. I understood her predicament. But childcare is not an illness.
There, in one consultation, is a weakness in the system. Social and economic problems arrive at the GP’s door requiring a medical solution. The available mechanism is a fit note, and the judgement falls to the GP. A welfare system loses credibility when ordinary pressures of life are sometimes converted into medical incapacity. Yet refusing a fit note does not make those pressures disappear.
Then there is the opposite problem: asking doctors to make judgements medicine cannot reliably make. Take PIP. PIP is not an out -of -work benefit and GPs do not decide entitlement. But the evidence we’re sometimes asked to provide illustrates a wider issue: asking clinicians for evidence about function they haven’t observed. Can the patient wash, dress, prepare food, communicate with others? These are primarily judgements about function, not straightforward clinical questions. I may see that person a handful of times a year. I can record that a patient says they struggle to dress. I cannot honestly say I’ve watched them dress, cook, travel, or interact outside my surgery. My response on the form will reflect that. With mental illness in particular, a short consultation doesn’t reliably tell me how someone functions across an ordinary day.
I can provide a diagnosis and describe what I’ve observed clinically, but there is a point at which evidence ends and assumption begins. Nor does a face-to-face assessment necessarily solve the problem. What determines incapacity cannot always be observed in an assessment room.
One response is to move these assessments away from GPs. There is merit in that; freeing clinical time would help. But changing who holds the form doesn’t necessarily answer the questions on it. The risk is that we simply transfer some of the same difficulties to another assessor. Any reform needs to recognise and mitigate that risk rather than move it elsewhere.
Even a comprehensive assessment answers only half the question. Suppose I think a patient could return to work. Return to what? I can make recommendations, but what happens when their employer can’t accommodate it? Large organisations may have occupational health: many smaller employers do not. Whatever the answer, it cannot be to place the burden on employers who have no more capacity than I do. Too often, the patient returns to my consulting room, and the only lever left is another fit note.
A patient unable to stand for eight hours may be perfectly capable of working for four. The space between not fit and fully fit is where many patients sit. Yet it is precisely the space our system struggles to manage.
GPs can describe the medical problem. We cannot create alternative duties, provide occupational health where none exists, or compel an employer to offer a phased return. Those assessing function should have the expertise to do so and where somebody is capable of some work, there needs to be a practical route back.
After years in general practice, I am convinced we ask too much of the GP consultation -to turn social problems into medical judgements, clinical information into assessments of daily function, and a fit note into a verdict on employment that we are not equipped to make.
This is not an argument for a particular welfare policy. It is a narrower point. Any reform that doesn’t reckon with what happens inside that consultation will run into the same wall.
It is crucial that we support those who genuinely need the state’s support. Equally the welfare bill matters, and so does fairness to the taxpayer.
The gap I see from my consulting room runs through the whole process, recognising what is really keeping someone from work, accurately assessing what they can do and, where they can work, creating a practical route back. But that route must also make economic sense. The calculation between what the welfare state provides, what work pays and the costs of returning to work cannot be ignored. None of this is straightforward. But addressing it piecemeal, means little changes.
Address them together, and real change becomes possible.