Medico-legal: Should you certify a patient 'fit for' an activity?

MDU medico-legal advisers Dr Beverly Ward and Dr Sissy Frank offers GPs advice about signing 'fit for' forms.

With travel operators reportedly slashing prices for overseas destinations amid sweltering temperatures in the UK, more families might be tempted by a bargain getaway. But airline passengers with health conditions may need to add obtaining a fitness certificate to their holiday to-do list. 

The MDU regularly gets asked by GPs for advice on whether they can certify a patient as fit to travel or take part in other activities so it makes sense for a practice to have a system in place for dealing with requests.

Consider the points below to ensure you comply with your professional obligations and avoid the medico-legal risks.

Be clear about charges

Doctors can charge for non-NHS work such as signing insurance certificates or forms to say that a patient is fit to travel or begin exercise. But it is advisable to be clear about charges in advance such as by publishing a list of fees on your clinic or practice noticeboard and website.

Some fitness certificates must be completed free of charge as part of your clinical practice. For example, GPs are contractually required to complete a fit note when a patient has been off sick for more than seven days.

Do your research

Ultimately it is the airline’s decision whether a person can fly, but you may be asked to give your medical opinion.

If asked to certify a patient’s fitness for any activity, it is prudent to find out as much as you can about the level of fitness required and whether the patient has any medical conditions or is taking any medication that might cause a problem.

For example, airlines generally provide specific guidance about their fitness to fly requirements so it may help to visit the website of the carrier concerned. The Civil Aviation Authority (CAA) also provides general advice for doctors about certifying patients for air travel1 which covers various conditions, including pregnancy, cardiovascular disease and passengers recovering from surgery.

The International Air Transport Association (IATA), which represents around 290 airlines, has also produced detailed medical clearance guidelines for its members.2 You should also advise the patient to check with their airline and insurance company if the patient has a condition that might affect their fitness to travel, as this could affect the validity of their insurance. This discussion should be documented in the patient’s notes.

But stick to what you know

If a patient asks you to certify them fit to fly shortly after surgery, you should first consider whether you are the most appropriate person to provide the certificate. The GMC in paragraph 14 of Good Medical Practice makes clear that a doctor 'must recognise and work within the limits of your competence'. You may feel a member of the surgical team is better able to given an opinion.

Doctors are also increasingly being asked to confirm that patients are fit to participate in a range of unusual or more adventurous activities like skydiving and charity treks.

If you are unfamiliar with the activity, it’s better not to make assumptions about the level of fitness required. Instead, you may wish to explain to the patient why you feel unable to sign the form, and suggest that he or she gets an opinion from a suitably qualified doctor such as someone with experience of sports medicine, or a specialist in the patient’s condition.

Choose your words carefully

If you feel able to sign a certificate the MDU’s advice is to ensure the wording reflects the facts and the limits of your knowledge. For example, rather than signing to say a patient is fit to participate in a particular activity or to travel, you may wish to provide a factual report detailing relevant information about the patient’s health conditions and explain that you 'know of no reason why the patient should not be fit for' the particular activity.  It is helpful to explain to patients why you are using those particular words as this should help them understand that you are acting responsibly and may avoid a potential complaint or claim. 

Give an informed opinion

Whatever the nature of the certificate, you will need to ensure that you have performed an adequate assessment of the patient’s condition, including any relevant examination or investigations. Assessments should be carefully documented as you may be asked to justify your statement at a later date.

Act with honesty and integrity

The GMC says that doctors 'must be honest and trustworthy… when completing or signing forms, reports and other documents', which means taking reasonable steps to verify the information is correct and not deliberately omitting relevant details, even if you come under pressure to withhold information. In this situation, it’s better to explain to the patient that you cannot complete the certificate without including relevant information. 

Confidentiality

You should obtain the patient’s consent to disclose confidential information about them, and document this within their medical record. It’s a good idea to provide a copy of a certificate or report to the patient before disclosing it to a third party.

The MDU has encountered cases where a patient has altered a document or forged a doctor’s signature. In these circumstances, it is not a breach of confidentiality to confirm that you did not create the document, or that any altered documents are not as they were when originally signed.

Don’t delay

If you have agreed to provide a certificate, this should be completed without unreasonable delay. The patient or their family may be depending on you.

References

  1. Assessing fitness to fly, Guidance for health professionals. Civil Aviation Authority, accessed July 2018
  2. IATA Medical Manual (11th edition), IATA, June 2018

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