GPs must comply with GMC guidance when issuing certificates for sick pay and benefits, but patients may try to persuade you otherwise, says Dr Gerard Panting


   

According to the Health and Safety Executive, economically active workers in the UK see their general practitioners with more than two million episodes of occupational ill health each year. More than one million people report sick each week and 80% of the 3000 people who remain off sick at 6 months will not work again during the next 5 years.1

Certification for statutory sick pay, maternity benefit and incapacity benefit are big, if not all together welcome, business for Britain's GPs. When issuing certificates GPs are expected to abide by the rules, but their patients may try to persuade them that certain diagnoses should not appear on certificates or that they are not fit for work when the evidence is based only on the patient's opinion.

The NHS GP's duty to provide certificates can be found in the general medical services regulations, which, to cut a long story short, require GPs to provide forms Med 3, Med 4, Med 5 and Med 6, plus certificates relating to maternity benefit, free of charge.

The GMC says that doctors must be "honest and trustworthy when writing reports, completing or signing forms and providing evidence in litigation and other formal inquiries."2 In addition the GMC states "You must take reasonable steps to verify any statement before you sign a document. You must not write or sign documents which are false or misleading because they omit relevant information."2

Sick pay

The Inland Revenue's statutory sick pay manual states "…a doctor's statement is strong evidence of incapacity and should usually be accepted as conclusive..."3

Employees cum patients are expected to self-certificate for the first 7 days of any illness, but once those 7 days have elapsed a medical statement is required from a doctor. For the first 28 weeks off work, employees receive statutory sick pay (SSP) from their employer. During this period the test to be applied by the doctor is the own occupation test (OOT), which predictably enough relies on whether "the patient, by reason of some specific disease or bodily or mental disablement is incapable of work which that person could reasonably be expected to do in the course of their occupation."4

After 28 weeks SSP gives way to incapacity benefit (IB), which is payable at a variety of rates. The test here (and for those with insufficient record of recent work) is the personal capacity test (PCA).

The requirement of this test is to judge "the extent to which a person, by reason of some specific disease or bodily or mental disablement is incapable of performing certain specific everyday activities set out in legislation."

To put it another way, is the patient fit to do some form of work even if they cannot return to their normal occupation?

Certificates

The form Med 3 is the most commonly used certificate, and requires the doctor to have examined the patient on the day the certificate is issued or the day before, stating either a specific date for return to work (a closed certificate) or a time period, for example two weeks, when the patient will be reviewed (an open certificate).

The rules governing issuing form Med 5 require the doctor to have seen (as opposed to having examined) the patient on the day of issue or the previous day. It differs from the Med 3 form in that it can be used in situations where the GP wishes to provide evidence of incapacity for an earlier period.

The guidance from the Department of Work and Pensions (DWP) states that you (the doctor) must:4

  • Base your advice on your examination of the patient on a previous occasion
  • Be sure that you would have advised the patient to refrain from work from the date of the examination for the entire period of the certificate.

Form Med 4 comes in to play prior to the first application of the personal capability test during a period of incapacity, and is usually prompted by the patient receiving a letter from the DWP. The Med 4 should include the diagnosis of the main incapacitating condition, other relevant medical conditions, and under 'doctor's remarks', some indication of the disabling effects of the patient's condition.

Form Med 6 is used where the doctor thinks it may be prejudicial to the patient's wellbeing to issue a certificate stating the true diagnosis – for example where a patient with a mental disorder and cancer phobia has developed cancer, and disclosure on the certificate is likely to cause serious harm to the patient's mental welfare. It should be completed at the same time as issuing the Med 3 or 4 and posted to the nearest DWP office. This normally triggers a request for a medical short report setting out the full diagnosis.

Every pad of Med 3 and Med 4 forms contains a few copies of form RM7, on which GPs can suggest an independent assessment of the patient's condition. This form may be used if the GP doubts whether the patient's incapacity is as serious as they claim.

Common problems with certification

Inevitably there will be circumstances where the doctor, although sympathetic to the patient's plight, will find it difficult to provide the certificate requested.

What if a patient has reached the end of his tether because he is being bullied at work? Too stressed to go in to work he asks to be signed off sick but fearing the consequences of being labelled mentally ill, he suggests that the absence is put down to flu.

Perhaps this is an occasion to use both a Med 3 and Med 6. This patient feels vulnerable enough already, and the GP will not want to do anything to damage their rapport. But on the other hand this problem is unlikely to go away, and there could, in due course be litigation in the employment tribunal. Therefore, whatever the GP does it must be recorded fully in the medical notes so if necessary a full chronology can be provided.

Another common problem is the mother who needs several weeks off work to look after a sick child. Is it legitimate to provide a certificate in these circumstances? Her GP cannot write a sick note for someone who is not ill, so unless she is incapacitated by the stress of her situation the answer will have to be no.

No doubt there are other ways to provide help, but bending the rules is not one of them.

Conclusion

Conflicts of interest are problematic in any profession, but in general practice they are more difficult because of the close relationship between doctor and patient, and the general expectation that the doctor will always be on the patient's side. But in addition to their duty of care to their patients GPs also have statutory responsibilities to comply with regulations and remain answerable to the GMC if they put their name to statements that are misleading or incorrect, especially if they do so deliberately.

References

  1. Health and Safety Executive. Presentation at the Royal Society of Medicine, 2005.
  2. General Medical Council. Good Medical Practice. London: GMC, 2001.
  3. Inland Revenue. E14(2005). What to do if your employee is off sick? London: Inland Revenue, 2005.
  4. Department of Work and Pensions. IB204. A Guide for Medical Practitioners. London: DWP, 2005.

Guidelines in Practice, April 2006, Volume 9(4)
© 2006 MGP Ltd
further information | subscribe