February 2002 GPC. General Practitioners Committee. Medical certificates and reports. Guidance for GPs

February 2002 GPC General Practitioners Committee Medical certificates and reports Guidance for GPs

Index Questions Page Access to Medical Reports Act 1988... q17...p6 Backdated certificates... q8... p3-4 Certificates and reports not covered by the GPs terms of service... q4...p2 Confidentiality... q13-15... p5-6 Duplicate certificates... q9...p4 Employers... q16...p6,13 Fees... q10-12...p4 Further reading...p8 GPs terms of service obligations... q2-3... p2,9-12 Incapacity benefit... q18...p6 Information to be provided in certificates and reports... q7...p3 Introduction......p2 Med 3 forms... q16...p6 Other professionals... q6...p3 Patient consent... q13-15,17... p5-6 Responsible doctor... q5... p2-3 Summary......p7 Workload... q18...p6 1

1. Introduction The GPC receives many queries from GPs and LMCs about the provision of medical certificates and reports. This guidance provides answers to the most common queries. 2. Which medical certificates must GPs provide under the terms of service? General practitioners have a statutory obligation, specified in their terms of service 1, to provide certain certificates free of charge to an NHS patient or their personal representative. Schedule 9 of the regulations lists the certificates reasonably required under enactments that are also specified in this schedule. Paragraphs 37 and 13 and schedule 9 are reproduced at appendix 1. 3. Which medical reports must GPs provide under the terms of service? Where a doctor has issued or refused to issue a medical certificate under their NHS terms of service they must provide any relevant clinical information about that patient subsequently requested by a medical officer. A medical officer means a doctor who is employed or engaged by the Department of Work and Pensions (previously Department of Social Security) or provided by an organisation contracted by the department. The certifying doctor is also obliged to answer any inquiries from a medical officer about prescription forms and certificates or reports provided under the terms of service. These obligations are contained in paragraph 48 of the terms of service (34 in Scotland), reproduced in appendix 2. GPs are strongly advised to read carefully through appendices 1 and 2 in conjunction with the relevant parts of the IB204 2 which is the authoritative guidance to doctors in relation to their role as certifying medical practitioners. 4. Are GPs obliged to provide certificates and reports not covered by the terms of service? No. It is for the GP to decide whether or not to do so. An exception to this is the provision of death certificates, required by statute. 5. Which doctor should provide a certificate or report? The doctor who has clinical responsibility for the patient s treatment. Paragraph 37(1)(a) of the terms of service (paragraph 13[8] in Scotland) applies (see appendix 1). For instance, hospital doctors should provide any certificates such as form Med 3 required for hospital in-patients, and out-patients 1 Para 37(1) and 48 of Schedule 2 to the NHS (General Medical Services) Regulations 1992 - as amended and Regulation 3 The NHS (Pilot Schemes: Part II) Practitioners Regulations 1998. In Scotland, the NHS (General Medical Services) (Scotland) Regulations 1995 - as amended and Schedule 3 para 12 of the National Health Service (Personal Medical Services) (Scotland) Regulations 2001. 2 Available at: www.dwp.gov.uk/medical. 2

for whose treatment they have clinical responsibility. Purchasers might specify in contracts that form Med 3 should be provided by a hospital doctor where appropriate. 6. Are other professionals allowed to provide certificates for social security purposes? Only a registered medical practitioner can issue official statements of a person s incapacity for work. The Social Security (Medical Evidence) Regulations 1976 (2) (as amended). The opinion of a health care professional (dentist, physiotherapist) would clearly be persuasive to an employer or benefit Decision Maker but would need to be provided on a certificate other than an official statement. The certificate should clearly identify the name, address and speciality of the practitioner. 7. What information should be provided in certificates and reports? Medical statements should record the advice given to the patient along with other factual information including an accurate diagnosis except on the occasions when a doctor feels that it could be prejudicial to their patient s wellbeing if the true diagnosis were given. The remarks sections on medical statements allow for additional comments about the disabling effects of the diagnosed condition, its treatment and prognosis. In cases where you consider that a patient would benefit from the help or advice of a Disability Employment Adviser (DEA) this opinion should also be included in the remarks section. Medical Reports indicate clearly the information required. Generally GPs should not speculate but should provide only factual information and should not certify something they are unable to verify. GPs should be aware of the following guidance from the GMC Good Medical Practice. Writing reports, giving evidence and signing documents You must be honest and trustworthy when writing reports, completing or signing forms, or providing evidence in litigation or other formal inquiries. This means that 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. If you have agreed to prepare a report, complete or sign a document or provide evidence, you must do so without unreasonable delay. 8. Are GPs required to provide backdated certificates? Requests for certificates and reports not included in the NHS terms of service is a matter to be decided between the GP and their patient. GPs should be familiar with the guidance issued by the DWP about providing back dated statements. Med 3 and Med 4 statements you must examine the patient on the day, or the day before, you issue these statements. They cannot be back dated. Med 5 statement can be used to supply evidence of incapacity for an earlier period but you must either: 3

base your advice on examination of your patient on a previous occasion providing you are sure that you would have advised your patient to refrain from work from the date of that earlier examination for the entire period of the certificate or, base your advice on a report from another doctor issued less than one month previously and issue form Med 5 for a forward period up to one month.. In any other circumstances it will be necessary for you to examine the patient and if you wish to supply evidence of incapacity for an earlier period you can: Issue form Med 3 for an appropriate forward period in keeping with your clinical findings from the date of your current examination with a note in the remarks section stating, for example, Has been unfit since.. (date) or The above diagnosis has been present since birth or; The above condition has been present since (date).. Retrospective information should only be provided where contemporaneous notes exist. GPs are reminded that they might be asked to provide further information to substantiate certification in such circumstances. 9. Are GPs allowed to issue duplicate certificates? GPs should be aware that they are not allowed to issue duplicate certificates relating to social security claims. An exception is where replacements are required for forms which have been lost. These should be marked duplicate. 10. Can GPs charge fees for providing certificates and reports? Not if they are being provided under the terms of service; reimbursement for the work involved is indirect, via GPs fees and allowances. (Exceptions to this are report form DS1500 and factual reports for disability living and attendance allowances, for which fees are payable by the Benefits Agency). GPs can charge fees for any certificates and reports not covered by the terms of service, with the exception of death certificates. Therefore it is for the GP to decide whether a charge should be made. In many cases this will be appropriate, but sometimes the ability to pay of the person or organisation requesting the certificate or report will be a factor to take into account. 11. What fee levels are appropriate? The BMA issues a series of guidance schedules suggesting fees for different types of work. These are available to BMA members, through the BMA website or BMA local office. (Addresses and telephone numbers can be found in the membership benefits handbook.) 12. To whom should fees be charged? The person or body requiring the certificate or report; in many cases this will not be the patient. 4

13. Is a patient s consent needed to disclose confidential medical information about him or her in a certificate or report? Yes. All information about a patient is confidential including the fact that they have been ill. Just grounds for disclosure are usually that the patient has given consent. NHS GPs are under a statutory obligation to provide certain information to a Medical Officer when requested by the Department of Work and Pensions under their terms of service 3 which provide that: a doctor shall, if he is satisfied that the patient consents, supply in writing to a medical officer within such a reasonable period as that officer, or an officer of the Department of Social Security on his behalf and at his direction, may specify, such clinical information as the medical officer considers relevant about a patient to whom the doctor under these terms of service has issued or has refused to issue a medical certificate. The Regulations further clarify that: For the purpose of satisfying himself that the patient has consented the doctor may (unless he has reason to believe that the patient does not consent) rely on an assurance in writing from the medical officer, or any officer of the Department of Social Security, that he holds the patient s written consent. The General Medical Council concurs with this advice and their publication Confidentiality: Protecting and Providing Information of September 2000 states at Section 4 paragraph 34b: If you are asked to write a report about and/or examine a patient, or to disclose information from existing records for a third party to whom you have contractual obligations, you must: Obtain, or have seen, written consent to the disclosure from the patient or a person properly authorised to act on the patient s behalf. You may, however, accept written assurances from an officer of a government department that the patient s written consent has been given. Such consent remains valid while a patient s claim is in effect, and not the period of incapacity, and is only superseded by a further claim. 14. Does a patient s signed declaration on form Med 3 or Med 4 constitute valid consent? This does seem to be acceptable for the purposes of giving valid consent. The wording of the declaration reflects good practice and current law in the sense that disclosure should always be the minimum which is necessary to achieve the objective. A doctor should make as clear as possible the scope of the disclosure to which the patient is agreeing. Doctors should also be aware that they are only authorised by the current wording on the forms to disclose information that is needed for assessment by the DWP in that particular case and not extraneous details. 3 In England NHS (General Medical Services) Regulations 1992 as amended and NHS (Pilot Schemes: Part II) Practitioners Regulations 1998. In Scotland, the NHS (General Medical Services) (Scotland) Regulations 1995 - as amended and The National Health Service (Personal Medical Services) Regulations 2001. 5

15. What if a third party has given consent? In some cases consent may have been given by a third party, for instance, a person who is making a benefit claim on behalf of a patient. Doctors must make a judgement as to the validity of this consent and therefore whether to release information would be appropriate. The interests of the patient must always be kept paramount. The BMA publication Medical ethics today: Its practice and philosophy (see Further reading, page 9) gives further consideration to circumstances where a patient cannot provide consent. 16. Are GPs obliged to issue Med 3 forms for periods of sickness lasting 7 days or less? No. If employers try to demand Med 3 forms in these circumstances, GPs may like to write to them using the model letter at appendix 3 or refer them to the doctor patient partnership leaflet Managing short term sickness or www.managingabsence.org.uk. 17. Can a patient see a report about him/her? The Access to Medical Reports Act 1988 (c28) allows patients access to medical reports written about them for insurance or employment purposes by a medical practitioner who is, or has been, responsible for their clinical care. The General Medical Council publication Confidentiality: Protecting and Providing Information of September 2000 clarifies the position with regard to reports provided to the Department for Work and Pensions (formally the Department of Social Security): The Access to Medical Reports Act 1988 entitles patients to see reports written about them before they are disclosed In some cases other bodies give patients access to reports, for example, the Department of Social Security gives all claimants access to reports made in connection with state benefits. In such cases it is not necessary for you to check patients wish to see the report. 18. What is being done to review and streamline the Incapacity Benefit medical procedures to reduce the workload of GPs? Much has been done by the GP panel of the Cabinet Office Regulatory Impact Unit, on which the GPC has two members and the Department of Work and Pensions (and its predecessor, the DSS), over the last 2 years to review and streamline the Incapacity Benefits medical procedures to ensure that a factual medical report is only requested in new incapacity benefit claims where there is no other reasonable option. The volume of IB medical reports requested by the Department has fallen from 30 per GP per year in 1995/1996 to fewer than 15 per GP per year in 2000/01. The DWP is seeking to develop new arrangements which will further reduce the workload for GPs in this area. At the time of writing, it was carrying out pilots of two solutions. The first involved the Department seeking the GP casenotes instead of requesting the completion of a factual report or MED4 form for new IB claimants. In the second, the Department would seek a shorter factual report form than the current IB 113 for review IB claimants. This would only ask the GP to detail any change in the clinical conditions since the last assessment. The outcome of these pilots will determine the suitability of rolling out new systems nationally. 6

19. Summary Some key points Certificates which GPs are obliged to issue are listed in schedule 9 to NHS (General Medical Services) Regulations 1992. GPs must provide reports requested by a medical officer about a patient to whom they have issued or refused to issue a certificate under the terms of service. They must also answer a medical officer s inquiry about prescriptions, certificates or reports provided under the terms of service. It is for GPs to decide whether to provide certificates or reports not covered by the terms of service, with the exception of death certificates which are required by statute. Fees cannot be charged for providing certificates and reports under the terms of service. Fees may be charged for other certificates and reports to the person or body requesting them; BMA members can contact their local office for advice on fee levels. Patient consent is usually required for disclosure of confidential medical information in a certificate or report. If a third party has given consent on behalf of a patient, a doctor must make a judgement as to its validity and therefore whether to release information would be appropriate. The Access to Medical Reports Act 1988 gives patients the right to see reports written about them for insurance or employment purposes. 7

20. Further reading Good medical practice/confidentiality (GMC, part of the Duties of a doctor guidance). Available from 178-202 Great Portland Street, London W1N 6JE. Tel: 0171 580 7642. Medical ethics today: Its practice and philosophy (1993) (BMA). Available from the BMJ Bookshop, BMA House, Tavistock Square, London WC1H 9JP. Tel: 0171 387 4499. Rights and responsibilities of doctors (1992 (BMA). Available from the BMJ Bookshop (contact details above). Medical evidence: Guidance for doctors and lawyers (BMA/Law Society). Price 1.40. Available to BMA members from BMA local offices or the secretariat of the BMA s Private Practice and Professional Fees Committee (PPPFC), BMA House (contact details above). Notes for guidance of doctors completing medical reports for life and permanent health insurance purposes (1992) (BMA/Association of British Insurers). Available free of charge to BMA members from BMA local offices or the PPPFC secretariat (contact details above). Non-NHS work by general practitioners (1996) (PPPFC). Available free of charge to BMA members from local offices or the PPPFC secretariat (contact details above). Guidance on medical records (1994) (GPC). Available free of charge to BMA members from local offices and to GPs who are not members from the GPC secretariat, BMA House (contact details above). Medical evidence for statutory sick pay, statutory maternity pay and social security incapacity benefit purposes: A guide for registered medical practitioners (IB 204) (1995) (Benefits Agency). Sent to all GPs in 1995. Further copies available via DSS free-phone 0800 868 868. Sickness certification and incapacity benefit: Bulletin one (7 March 1996) (Benefits Agency). Sent to all GPs. 8

Appendix 1 Paragraph 37 of the terms of service: Certification (1) A doctor shall issue free of charge to a patient or his personal representatives any medical certificate of a description prescribed in column 1 of Schedule 9, which is reasonably required under or for the purposes of the enactments specified in relation to the certificate in column 2 of that Schedule, except where, for the condition to which the certificate relates, the patient: (a) (b) is being attended by another doctor (other than a partner, assistant or other deputy of the first named doctor); or is not being treated by, or under the supervision of, a doctor. (2) The exception in sub-paragraph (1)(a) shall not apply where the certificate is issued pursuant to regulation 2(1) of the Social Security (Medical Evidence) Regulations 1976 (which provides for the issue of a certificate in the form of a special statement by a doctor on the basis of a written report made by another doctor). (3) Any certificate given under sub-paragraph (1) for the purpose of: (a) (b) (c) the Social Security Act 1975 shall be issued in accordance with any regulations made under that Act; section 17(2) of the Social Security and Housing Benefits Act 1982 shall be issued in accordance with any regulations made under that Act; or Part V of, and schedule 4 to, the Social Security Act 1986, shall be issued in accordance with any regulations made under that Act. From paragraph 13 of the Scottish terms of service: Treatment of patients (7) A doctor shall issue to a patient or his personal representatives free of charge any certificate of a description prescribed in the first column of schedule 9 which is reasonably required by him under or for the purposes of the enactments specified in the second column of the said schedule opposite and in relation to the description of the certificate in the first column. Any certificate issued under this sub-paragraph for the purposes of: (a) the Social Security Act 1975; or (b) section 17(2) of the Social Security and Housing Benefits Act 1982; or (c) part V of and schedule 4 part I to the Social Security Act 1986 shall be issued in accordance with any regulations made under those Acts. (8) A doctor shall not be required to issue a certificate under this paragraph where the patient is receiving treatment otherwise than from or under the supervision of a doctor.

Schedule 9 to the NHS (General Medical Services) Regulations 1992: List of prescribed medical certificates Description of medical certificate 1. To support a claim or obtain payment either personally or by proxy; to prove inability to work or incapacity for self-support for the purposes of an award by the Secretary of State; or to enable proxy to draw pensions etc. 2. To establish pregnancy for the purpose of obtaining welfare foods. 3. To establish fitness to receive inhalational analgesia in childbirth. Short title of enactment under or for the purpose of which certificate required Naval and Marine Pay and Pensions Act 1865, Air Force (Constitution) Act 1917, Pensions (Navy, Army, Air Force and Mercantile Marine) Act 1939, Personal Injuries (Emergency Provisions) Act 1939, Pensions (Mercantile Marine) Act 1942, Polish Resettlement Act 1947, Home Guard Act 1951, Social Security Act 1975, Industrial Injuries and Disease (Old Cases) Act 1975, Social Security and Housing Benefits Act 1982 pts I and III, Social Security Act 1986 pt II, pt V and sch 4. Social Security Act 1988 section 13. Nurses, midwives and Health Visitors Act 1979. 4. To secure registration of stillbirth. Births and Deaths Registration Act 1953/Registratrion of Births, Deaths and Marriages (Scotland) Act 1965. 5. To enable payment to be made to an institution or other person in case of mental disorder of persons entitled to payment from public funds. 6. To establish fitness for jury service/to establish unfitness for jury service in Scotland. Mental Health Act 1983 section 142. Juries Act 1974/Criminal Procedure (Scotland) Act 1975, Court of Session Act 1988. 7. To establish unfitness to attend for medical National Service Act 1948. examination. 1 8. To support late application for reinstatement in civil employment or notification of non-availability to take up employment, owing to sickness. 9. To enable a person to be registered as an absent voted on the grounds of physical incapacity. 10. To support application for certificates conferring exemption from charges in respect of drugs, medicines and appliances. 11. To support a claim by or on behalf of a severely mentally impaired person for community charge exemption. 12. To support a claim by or on behalf of a severely mentally impaired person for exemption from liability to pay the Council Tax or eligibility for a discount in respect of the amount of Council Tax payable. 2 Reinstatement in Civil Employment Acts 1944/1950, Reserve Forces Act 1980. Representation of the People Act 1983. National Health Service Act 1977/National Health Service (Scotland) Act 1978. Local Government Finance Act 1988/Abolition of Domestic Rates etc (Scotland) Act 1987. Local Government Finance Act 1992. 1 Absent from schedule 9 of the Scottish GMS regulations. 2 This paragraph added by the NHS (General Medical Services) Amendment Regulations 1993.

References for certificates commonly requested under schedule 9 Category 1 Statutory sick pay and state incapacity benefits: Med 3, Med 4, Med 5, Med 6 Statutory maternity pay and state maternity benefits: MAT B1 Disability living allowance: DLA 1, DLA 1A, DLA 1 Welsh, DLA 1 Child, DLA 434, DLA 580, DLA 581, DLA 582 Attendance allowance: DS 2, DS 2A, DS 263, DS 1140 Category 4 Medical certificate of stillbirth - 34. Category 5 No prescribed certificate; this is usually produced as a letter with no fixed format. Category 10 (9 in Scotland) FW8 and FP92A NB: GPs are reminded that they are obliged, by statute, to provide death certificates. (This is separate from their terms of service obligations.)

Appendix 2 Paragraph 48 of the terms of service: Reports to medical officer etc A doctor shall: (a) (b) supply in writing to a medical officer within such reasonable period as that officer may specify, any relevant clinical information which he requests about a patient to whom the doctor under these terms of service has issued or has refused to issue a medical certificate; and answer any inquiries by a medical officer about a prescription form or medical certificate issued by the doctor under these terms of service or about any statement which the doctor has made in a report under these terms of service. Paragraph 34 of the Scottish terms of service: Reports to the medical officer A doctor is required: (a) (b) (c) to furnish in writing to the medical officer within such reasonable period as the latter may specify any information which he may require with regard to the case of any patient to whom the doctor has issued or declined to issue a medical certificate, to meet the medical officer, at his request, for the purposes of examining in consultation any patient in respect of whom the doctor has sought the advice of the medical officer, and to make available to the medical officer, upon notice being given, the records kept by the doctor under these terms of service and to furnish to the medical officer any information desired by him with regard to any entry therein or with regard to any prescription or certificate issued by the doctor under these terms of service. 12

Appendix 3 Model letter Dear........... It has been drawn to my attention that members of your staff are required to provide medical certificates to support an absence of... days. GPs are obliged to issue certificates for social security purposes only for episodes of illness lasting 8 or more days (including weekends). Thus no GP is required to issue free of charge or otherwise a certificate for absence through sickness for 7 days or less (including weekends). Although GPs may issue a private certificate in such circumstances, and charge you a fee for doing so, we try to encourage employers not to rely on medical certification for short periods of incapacity. It is difficult for a doctor to judge whether or not a patient was incapable of reporting for work in this situation and all the certificate is really indicating is that the patient presented himself at the surgery on a specific date complaining that (s)he had been ill on the previous day. Control of excessive absence is a task which falls more appropriately to managers. Yours sincerely Dr.......... 13