Get a note from your doctor

From Ganfyd

Statutory certificates

There are a number of statutory certificates in use in the United Kingdom. GPs are paid for issuing these as part of their basic contract: there is no specific fee for issuing them, and doctors are duty-bound to issue them, where appropriate. Where patients are under the care of a hospital, the hospital (not the GP) should issue the sick note.^[2][3][4]

The certificates are, however fairly limited in their purposes, and cannot be issued for other purposes. A standard "sick note" is issued for the purposes of claiming statutory sick pay, for example, and cannot be used to confirm, say, that a child who has missed school was genuinely ill. (Sick notes are not required in these circumstances; although if a child regularly misses school, there may be a role for medical input.^[5])

See Incapacity assessment for more information on statutory certificates.

Fit note

From 6 April 2010 "sick notes" (the old Med 3 and Med 5) will be replaced by "fit notes". See e.g. this story in Pulse for more information; and here for a sample.^[6] More information about these is available at the "fit note" page of the Department for Work and Pensions' web site. Further information and leaflets for the following audiences can be downloaded there:

• General Practitioners and other doctors from this page.^[7]
• (via the Business Link web site)
• Employees and patients (via the DirectGov web site)

Patients sometimes claim that their employer does not accept self-certification forms for periods of illness of less than 7 days. If this is true, the employer can be referred to government guidance that states: "After the seventh day, you can ask for reasonable medical evidence but can only ask for a doctor’s statement after the first seven days in a spell of sickness. You can then ask for regular doctor’s statements to cover the balance of the sick absence." (p14)^[8]

See also:

• Department for Work and Pensions
• NHS Choices guide to fit notes
• DirectGov guidance on sick pay
• Employer helpbook for statutory sick pay from HMRC

Other requests for doctor's notes

Patients will sometimes consult with a view to getting a note from their doctor. Some of these requests for letters are reasonable. For instance, in insurance medical reports where some knowledge of the patient's medical background is important and so the GP has something useful to contribute.

Sadly, many of these requests range from unnecessary to frankly absurd. Many are requested by people in positions of administrative responsibility who are not willing to believe information supplied by the patient, seek to avoid or shift legal responsibility for potential adverse consequences, or choose to impose effort and cost on the patient regardless of the effects on other services. Examples include letters to certify fitness to travel, fitness to work and fitness to undertake certain activities, e.g. acting, modelling, sitting examinations, using the gym, starting an exercise/diet programme, parachute jumping, diving etc.

At other times patients may come for letters on their own initiative, often in an attempt to recruit the doctor's support to avoid something undesirable, e.g. justifying an absence from work, trying to get off a speeding fine, etc.

It used to be the case that doctors were frequently asked to countersign applications for official documents such as passports or driving licenses. The government has made it very clear that doctor time for this is not funded by taxpayers money, and this should no longer be necessary.^[9]. Separate paid arrangements with patients who find it convenient remain possible.

Fees and Payment

Regardless of how valid the request may be, these letters are a form of medical report. They are therefore classed as private work and attract a fee. This should be made clear to the patient. As these letters fall outside normal NHS duties, doctors can decline to supply these letters as there is no contractual obligation to provide them (although there may be a moral obligation in some cases).

Unhappy as patients may be about this, the need for payment often filters out most of the unnecessary requests. Unnecessary administration can be reduced to a minimum by providing the letters only after payment of the fee, either by the requesting organisation or by the patient. Some practices stipulate payment in cash as patients have been known to cancel cheques! If the letter is issued but the patient refuses to pay, recovering the fee is awkward, unlikely to be successful and probably not worth the effort. The letter below is a useful way of both requesting payment and deflecting the more frivolous requests.

The fee for a letter may be waived in certain circumstances, but bear in mind that if you routinely give out letters for free, you run the risk of perpetuating the demand for these letters. Given that many otherwise well patients book appointments for what is essentially a non-medical problem, it also devalues the GPs time. Doctors in partnerships, or employed by organisations entitled to make money must also consider that in providing such a service free they may be failing in their duty to the partnership or employer.

Many GPs see such requests as a "waste of time". Whether this is true or not probably depends on their attitude to income generation. If they charge a fair price (which means that the practice makes a profit from the transaction), then it's legitimate business, earning money for the practice. If they charge a token amount which means that it costs the practice money, then it's a waste of time (and NHS money). The fact that failing to charge a fair price means that the NHS is subsidising private work is sufficient reason to not do such work, or to charge appropriately high prices for doing so.

Medico-legal Considerations

Certain areas should be left to doctors with appropriate expertise:

• Fitness to drive - Driver and Vehicle Licensing Agency (DVLA) have dedicated doctors
• Fitness to fly - particularly in patients with respiratory disease that require further testing (see Aviation medicine)
• Occupational health assessments - most companies should have their own or should request this from an appropriately qualified occupational health doctor
• Recording injuries for police purposes.^[10]

Requests may ask you to certify that a patient is fit to do a certain activity. As life is unpredictable and doctors are not prescient, it is best to phrase your reply to say that you "do not know of any reason why they cannot participate in this particular activity".

Articles about GANFYDs in press

• An excellent article from the Association of Clinical Pathologists Newsletter reproduced with permission of the author, Dr Peter Davies, GP:
  • http://www.ganfyd.org/images/GANFYD_ACP_news.doc - MS™ Word Document format (45Kb, virus-free).

General note

A general note which can be adapted to suit all requirements from housing to schools/colleges and workplace problems

Date:



Dear Sir/Madam

Name:
Patient Address:

My patient has requested that I send you details of his/her medical history in so far as this is related to employment / workplace needs. I would be grateful if you would confirm your need for this information and complete the details below:

Precise information required:
_________________________________________
_________________________________________

I consent to the above information being given by my GP to my employer.

Patient’s signature: _________________________________________

Print Name ___________________________ Date ______________

Date by which GP response is required (at least 7 days from receipt of your reply to this request):
_________________________________________.


The company accepts responsibility for the fee payable for this service (£20-50 depending on requirements).

Signature (employer): ___________________________ Date ______________
Please print name and position: _________________________________________

In the event that this information is not required I will assume that the patient themselves can supply you with all necessary details.

Yours faithfully

General Note in Electronic Format

• The Universal Ganfyd Deflector™, courtesy of Dr Roger Leary, GP:
  • http://www.ganfyd.org/images/GANFYD.doc - MS™ Word Document format (35Kb, virus-free).
  • http://www.ganfyd.org/images/GANFYD.pdf - Adobe™ Acrobat format - Interactive to enable form to be filled in prior to printing (222Kb, virus-free).

Diabetic Note

Practice details as stamp




My patient _____________________ is diabetic and requires Insulin.

Please assist him/her to carry Insulin within aircraft cabins.

My reference for this security document is ___________________.

Contact may be made between 0900 and 1700 GMT monday to Friday to confirm it.


Signed ....................


Stamp



Fee

Self-certification

Patients can self-certify for illnesses of less than 7 days (see self certification rules, or download a copy of the self-certification form here). Despite clear guidance on this matter, some employers will nonetheless request that the patient produce a 'sick note', often out of mistrust of their employees, or in an attempt to police casual absences. A useful note to return to the employers is set out below (courtesy of Dr G.D. Butchart).

Request for certification for absences less than 7 days

Re:

Employers asking for a doctor’s statement for the first seven days of an employee’s sickness are
referred to the Statutory Sick Pay Manual for Employers – National Insurance Contributions Series
CA30, Paragraph 28, which states “you (the employer) cannot ask for a doctor’s statement for seven
days or less of a spell of sickness”.

The purpose of this regulation is to avoid the necessity for employees with minor, self-limiting
illness or injury to use surgery appointments for the sole purpose of obtaining a medical
certificate. I do not therefore issue certificates in these circumstances.

If employers have reason to inquire about a spell of sickness, they are advised to write to the
doctor, including written permission from the employee concerned, when a report may be issued.

A charge will be made for such a report for which you, the employer, will be responsible.

Yours sincerely,

Sick notes for exams

GCSE, GNVQ, GCE, VCE, AEA and Entry Level examinations are covered by the Joint Council for Qualifications (JCQ).

If a student is unable to attend an exam due to illness, they should be eligible for special consideration. The JCQ questions and answers ask Does an awarding body need medical notes in each case?, and answer:

Providing a letter or medical certificate for an absence for an examination is clearly not part of NHS duties, so a GP can refuse to do this, or can charge a fee to do so. The BMA has recently (2010) sought and received clarification that this is the case.^[11]

"Sick notes" for court appearances etc.

It is not uncommon for patients to request "sick notes" to explain why they did not attend, or cannot attend, court. In some instances such requests may be motivated by an understandable anxiety due to the fact that they know they are likely to be found guilty of an offence.

All such requests must come from the courts. Doctors who have provided sick notes for such purposes, other than at the request of the court have, in the past, been heavily censured, and risk being found to be in contempt of court.

Note, also, that Med 3 and self-certification certificates are for statutory sick pay purposes only, and should only be used for statutory sick pay.

Similar rules apply for patients who want evidence to excuse themselves from jury service (see also #External Links), community service, or probation.

If a patient requests a "sick note" because they are anxious about appearing as a witness, they might find it helpful to visit Witness Walkthrough, and they should contact the court for advice about the witness counselling and protection services that are available.

Sheffield LMC has provided guidance for GPs on this issue.

Guidance is available regarding "soul and conscience" letters in Scotland.

GP Dr Roger Leary has posted that he issues a letter along the following lines when he receives such requests:

To whom it may concern


Confirmation of attendance by a General Practitioner


Date and Time………………………………………………………
Name…………………………………………………………………
DOB………………………..……………………………….…………
Address………………………………………………………………


Dear Sir/Madam,

I confirm that this person came to see me today.
I confirm that they are suffering from

…………………………………………………………………..…….

I have advised the person concerned that any statement I provide regarding this illness does not excuse any failure to attend court as this can only 
be at the direction of the Court.


Yours Sincerely

External Links

• Department for Work and Pensions "Doctors Obligations" document "IB204"^[12]
• Children and the Stage
• JCQ (formerly JCGQ) Regulations on special circumstances in school exams
• Jury service guidance Which says inter alia 'You may be excused for medical reasons. You should only obtain a medical certificate if you are asked to provide one by the Jury Central Summoning Bureau'(Note that this only applies in England and Wales. In Scotland, different rules apply.)
• Department of Work and Pensions guides
• Department of Work and Pensions guidance on when a hospital, not a GP, should issue a sick note

References