Have GPs lost the ability to say no to their patients? I ask because a BBC survey published last week, based on more than 750 family doctors, found that 72 per cent say they have never refused a patient’s request for a sick note.
Consider what that really means. Of the more than ten million written statements – known as fit notes – issued last year, nearly one in ten cited mental health or behavioural disorders that were allegedly so severe they prevented patients from working.
But not only does the BBC’s survey suggest GPs rarely interrogate whether this is actually true, the reality is also that they don’t always even see the patient before issuing one.
One GP told me that if repeat patients request a fit note, no consultation is even booked in – just a pop-up reminder for them to issue the correct paperwork.
Can it possibly be true, then, that nearly one million people last year – one in 40 of the UK’s working-age population – were so badly affected by mental and behavioural health disorders that they needed time off?
Or is it something arguably far more likely: that our GPs – once the gatekeepers of our great NHS – are now more commonly bowing to patient demands?
What that means, of course, is otherwise-healthy people are being encouraged in their belief that they are genuinely ill.
I see them every day. As a teacher to children increasingly being diagnosed with myriad mental health and behavioural problems, I’m for ever being told this is a reason for them being unable to attend mainstream education.
Like fit notes, the issuing of autism referrals is fast becoming a formality for GPs
My pupils often say: ‘My GP says I’ve got anxiety so I can’t go to school’; or, ‘I’ve been diagnosed with autistic spectrum disorder [ASD] so I can’t socialise’.
The prevalence of such disorders is rising. The latest NHS data suggests one in five children had a probable mental health condition in 2023, up from one in eight in 2017. But many of these children may well have other explanations for their behaviour.
One of my pupils, 14-year-old Sandie (not her real name), was diagnosed with ASD when she was 12. She told me the real reason for her challenging behaviour was not mental illness, but her home life.
‘I had to move in with my aunt because my dad couldn’t cope,’ she said. ‘I was p****d off. I didn’t want to go to school and started bunking off.’
She said this acting out triggered ‘all these people’ to come to her house, including an educational needs practitioner and occupational therapist, and she was referred to CAHMS, the Child and Adolescent Mental Health Service. ‘I said I’d kill myself, [and] got an appointment after a few months,’ Sandie said. ‘I had my hood up, didn’t talk to her, played with my phone. Got told I was autistic.’
But two years on, Sandie doesn’t think she has autism at all and wants another appointment to prove she’s ‘OK’. I don’t believe Sandie is an isolated case, as the system favours over-diagnosing conditions such as these.
What often happens is that patients like her, who have caused problems at home or in school, see a GP with parents convinced they ‘must’ have a disorder.
GPs use a standard questionnaire to provide an initial assessment before referring them on to CAHMS or other NHS providers who make ADHD and autism assessments. But the problem with this questionnaire is that it is easily gamed. Patients, or their families, can turn up with prepared answers they’ve picked up online or on AI chatbots to questions they know will be asked.
The lack of rigour in GPs’ decision-making and reluctance to say no are setting up a generation to fail
Like fit notes, the issuing of autism referrals is fast becoming a formality for GPs, rather than what it should be – an interrogation of the patient and their symptoms.
While few physical symptoms would simply be referred on to specialists without an initial examination, mental health issues are given a free pass.
The GPs I have spoken to say grilling a patient and refusing a referral would ‘interfere with the doctor-patient relationship’. They add that, for autism and ADHD, ‘specialists are better placed to make such diagnoses’.
It’s true those seeking such medical labels often have a complex lifestyle of social and emotional behaviours that are impossible to unravel in a short appointment.
But when the buck is so easily passed from the GP to educational psychologists or psychiatrists, it can put a child on a medical path that is nearly impossible to leave.
Once their behaviour is pathologised as a disorder, they believe it. It absolves them from addressing their real problems, such as overeating, nocturnal living patterns and excessive tech use.
One of my pupils, Kelly-Jane (again, not her real name) was diagnosed with autism aged 11. She found the transition to a very unruly secondary school difficult.
Gradually, she stopped attending. Her concerned parents paid for a private assessment costing £1,800 that led to a diagnosis.
As a result, Kelly-Jane became one of the 149,000 children in England and Wales to get an Education, Health and Care Plan (EHCP) specifically for autism in 2025. These plans come with a suite of financial benefits to support their educational needs until they turn 25 or get a full-time job. But that means teaching firms such as mine are disincentivised from encouraging our pupils into employment – if they’re no longer in full-time education, we won’t receive government funding.
So girls such as Kelly-Jane and Sandie are robbed of ambition and will likely claim benefits for the rest of their lives. It is nothing short of a national scandal.
Given Sandie’s disrupted home life and Kelly-Jane’s unpleasant school experience, their behaviour is easily explainable without a medical label – something I suspect even the godmother of autism, Dame Uta Frith, would agree with.
Dame Uta is emeritus professor in cognitive development at University College London. She recently suggested that describing autism as a spectrum has been ‘stretched so far that it has become meaningless and is no longer useful as a medical diagnosis’.
And yet the mass diagnoses continue, partly because the guidance GPs follow is so hopelessly woolly. The most common diagnostic manual says autism sufferers may display ‘abnormal social approach and failure of normal back-and-forth conversation’.
In other words, they are a typical moody teenager.
I understand GPs are under ever-greater pressures. But they must remember their role as patient assessors, not abettors. The lack of rigour in their decision-making and reluctance to say no are setting up a generation to fail.