Medical management - Understanding medical certs

Familiarise yourself with the different medical certificates and their uses, says Dr Lizzie Croton.

As a GP in training, you will receive daily requests for correspondence, certificates and letters regarding your patients and their work issues. It is useful to be familiar with the medical certificates that you are obliged to provide under the NHS and the circumstances under which they can be used.

More detailed information regarding certificates can be found at the Department for Work and Pensions (www.dwp.gov.uk or see www.healthcarerepublic.com/sicknotes).

Statistics tell us that the longer a person has off work, the less likely they are ever to return.

Consider the alternatives before signing someone off work - it may be appropriate to suggest adjustments to work (via the remarks section of the Med 3 certificate) or a graduated return to ease the patient back in. Where possible you should encourage the involvement of the occupational health service.

Med 3
Legally, we are required to provide a certificate of incapacity to work due to illness if the illness lasts for more than seven days, which includes Sunday.

Usually a Med 3 is used, and this is filled in by the GP when the patient is seen in surgery. An assessment of the patient's capability to do their job should be carried out. If the illness is expected to last less than 14 days, a return-to-work date can be given on the certificate. This is a 'closed' certificate.

If the illness is expected to last longer, a period of time can be stated instead (for example, three months) and the certificate left 'open'. A patient should be reassessed before they return to work and issued with a final 'closed' Med 3.

The doctor is able to issue a Med 3 up to one day after the patient was seen. There is space at the base of the form to write a reason for absence. If a certificate is lost, a replacement can be issued but must be endorsed 'duplicate'.

Med 5
A Med 5 certificate is used when a doctor has not seen the patient but has access to a written report from another doctor, such as an hospital outpatient letter, and is satisfied that the patient should not be at work. The forwarding period covered on the certificate should not be more than one month.

A Med 5 can also be issued if the certificate is requested by the patient more than one day after they were seen.

Both Med 3 and Med 5 enable a patient to claim statutory sick pay (SSP) from their employer for a period of 28 weeks.

If the patient is not eligible for SSP (for example if he or she is self-employed), they are able to claim incapacity benefit provided they have done a substantial amount of work in the 21 weeks prior to their illness.

Med 4
You will probably be asked to complete a Med 4 certificate at some point in your training period. This is requested when a patient has been receiving a Med 3 certificate for more than 28 weeks.

The patient is sent an IB50 form from the DWP to complete, and asked to obtain a Med 4 from their GP. This certificate requires the GP to fill in a short paragraph about the condition, its effect on the patient's life and its prognosis.

The DWP will then make a decision on the basis of the report as to whether the patient can continue to receive benefits or if they need further assessment via a DWP medical examination.

Med 6 and RM7
The remaining two medical certificates are used less often but commonly feature in MRCGP exams. Med 6 is used when it is felt that putting the full diagnosis on a form would be harmful to the patient directly or via their employer knowing the diagnosis.

A 'vague' diagnosis is given and the DWP can request further information from the GP.

An RM7 form is used where there is doubt as to the patient's incapacity, for example if the doctor suspects that the patient might be malingering.

The form is sent to the DWP, usually without the patient's knowledge, and they will then arrange early review of the patient to assess the situation.

Self-certification
Patients do not require a doctor's note if they have been off work for less than seven days. They can self-certify using either SC2 (for those eligible for SSP) or SC1 (for those not eligible for SSP). These are available from surgeries and Job Centres.

Other sick notes
You will almost certainly be asked for a doctor's note for work absences of less than seven days. I was once asked for a note to cover 30 minutes off work.

We are not obliged to provide such notes, but it can be difficult to manage such consultations when patients are anxious that they might not get paid.

Surgeries have different strategies for dealing with such requests so ask if you are not sure. Most will provide a private sick note in this case (around £7-£11). Whatever approach you take, be consistent and always be the patient's advocate.

 Learning points

1. Be familiar with the different types of certificates and when they can be used.

2. Keep pads of certificates safe - they are a target for thieves and can be as valuable as FP10s in the wrong hands.

3. Document clearly in the notes what certificate you have given the patient, the dates stated and the diagnosis entered on the form.

4. Consider alternatives to signing the patient off work, such as a gradual return to employment.

5. Where there are doubts about a patient's capacity to work, use the RM7 form to prompt early assessment by the DWP.

Dr Croton is a GP registrar in Birmingham

Contact Sharon Pickett at GP Education on (020) 8267 4512 or email GPclinical@haymarket.com


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