Get a note from your doctor

Contents 1 Statutory certificates 2 Fit note 2.1 Guidance on how soon a patient can return to work 2.1.1 Return to work notes 3 Self-certification 4 Other requests for doctor's notes 4.1 Text for letter when requested for gym/sporting activities 4.2 Occupational health requests and NHS providers 4.3 Medication in schools and other childcare settings 5 Fees and Payment 6 Medico-legal Considerations 7 Articles about GANFYDs in press 8 General note 8.1 General Note in Electronic Format 9 Diabetic Note 10 Sick notes for exams 11 Concessionary bus passes 12 Fit notes for attending a gymnasium 13 "Sick notes" for court appearances etc. 14 External Links 15 References

There are, of course, occasions when it appropriate for doctors to provide notes for their patients.

This page is intended to help doctors decide whether it is appropriate - and/or part of their contractual obligation - to do so in particular situations.

Some readers may be concerned that it seems inappropriate for doctors to decline to do work because they consider it inappropriate, or because it's not in their contract; or to ask for payment for non contractual work such as employment or insurance medicals. However, most doctors already work more than they are paid to do; and any time spent on work which is not part of their job is time they cannot spend doing their job: there is an opportunity cost. It is not reasonable to expect doctors to work for free.

The BMA has published useful guidance for GPs, including several template letters.^[1]

Statutory certificates

There are a number of statutory certificates in use in the United Kingdom, largely related to statutory benefits. 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])

Any registered medical practitioner working for the NHS or privately, including junior hospital staff can obtain their own MED3s on request to the appropriate NHS supplier. All they need to do is to fax an order on headed notepaper to:

0161 683 2450

Security Printing systems limited, Gorse Street, Chadderton, Oldham

(Or see DWP guidance)

See Incapacity assessment for more information on statutory certificates.

Fit note

Since 6 April "sick notes" (the old Med 3 and Med 5) have been replaced by "fit notes". See e.g. this story in Pulse for more information; and here for a sample.^[8] 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:

• Getting the most out of the fit note: Guidance for employers an line managers^[9]
• Getting the most out of the fit note: GP guidance[10]
• DWP Guide for hospital doctors^[11]
• General Practitioners and other doctors from this page.^[12]
• (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)^[13]

Paula Wright has created a 10 minute Youtube video with guidance for hospital doctors on fit notes - it's good CPD!^[14]

Guidance on how soon a patient can return to work

The time a patient will need before they return to work following an illness or procedure will, of course, vary, and depend upon the patient's constitution and motivation, as well as the nature of the illness or procedure.

General guidance is, however, available, including:

• Fitness after surgery from Working Fit.

Return to work notes

Patients sometimes state that, after their certification as unfit to work expires, their employer requires a note to certify that they are now fit to work. One practice has a supply of a leaflet available at the reception desk, as follows:^[15]

“Return to work” notes Since 6th April, the old-style sick notes have been replaced with new “fit notes”. One of the changes that have been made is that we can certify that someone is fit for work with certain adaptations in the workplace. However, there is no longer any requirement for doctors to provide notes stating that their patient is fully fit for work. The following is guidance from the Department of Work and Pensions: ^[16]

Can I request a Medical Statement advising that my employee is ‘fit for work’?

Unlike the sick note, the Statement of Fitness for Work does not include the option for doctors to advise someone that they are fully fit for work. You do not need to be fully fit to return to work and it is a myth that an employee needs to be ‘signed back’ to work by a doctor. […] If you feel you need a medical opinion stating that your employee is fit for work you can enter into a private arrangement with a GP or occupational health specialist.

As a result we are no longer providing “return to work” notes routinely. If you do require a report regarding a patient’s suitability for work we can provide one privately for £25 – please write to us at the address below enclosing written consent from your employee, and a job description.

The DWP guidance mentioned above states, on page 8:

Does my employee need a fit note saying they are fit for work?

No. People do not need to be signed back to work and there is no option on the fit note to do so. If your employee’s doctor assesses that they are fit for work, they will not be issued with a fit note.

Your employee should return to work once their fit note expires (if they have not already done so) or will need a new fit note.

For a limited number of jobs, there are separate procedures to ensure someone is fit to carry out their role. Your HR, occupational health or legal department should know if this applies to your organisation.

If your organisation has a separate policy which requires someone to obtain medical evidence that they are fit for work, this should be arranged through a private arrangement with a GP or occupational health specialist. Once your employee’s doctor has assessed them as fit for work, they cannot issue any further fit notes to cover a period while they are waiting for additional health checks required by your organisation.

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
• Sick note to fit note. Statement of fitness to work: a guide for hospital doctors from the DWP.
• Understanding Fit Notes (Pulse)^[17]

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,

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.

Doctor's may be asked to act as referees for patients wishing a firearms license. This is not NHS work - see the firearms page for more information.

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. Indeed some bodies require individuals to provide a medical certificate of their fitness to participate in certain activities. Children participating in professional performances are an example (which has been discussed from time to time in Doctors - this thread, for example, includes various suggestions.

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.^[18]. Separate paid arrangements with patients who find it convenient remain possible.

Text for letter when requested for gym/sporting activities

This is a draft suggestion... Before such a letter could be written the patient (if they have capacity) would have to provide formal, written consent, and an appropriate fee would have to be agreed (and paid).

"I am not an expert in sports medicine and cannot state whether xxx is fit to participate in gym or sporting activities, in this case (edit as appropriate here). However, physical activity is generally good for people's mental and physical health, so I would not wish my patient to be deprived of participation in sporting activity or exercise without good reason.

"This patient (edit as appropriate; e.g. 'has a learning difficulty, and this is associated with a moderate degree of dyspraxia, which makes them less well coordinated than most people' or 'mild hypertension, well controlled on medication'...). This should be taken into account."

Occupational health requests and NHS providers

Many patients are referred to NHS providers for, for example, pre-employment screening (including checking their medical records) or vaccination. These services should be provided by the employer. NHS providers who provide such services should not do so "on the NHS". GPs may do such work, but it should not be charged to the NHS; in other settings the work should not be done at all, certainly not in NHS time, unless it is paid for by the employer.

Note that pre-employment requests such as that in the quotation box (an actual case) should be referred back to the employer. (It is particularly invidious that people applying for relatively low-paid jobs such as healthcare assistant posts should be asked to fund this themselves.)

Useful guidance on this is provided in the following documents:

• Blood-borne viruses in the workplace: guidance for employers and employees from Health and Safety Executive^[19]
• The Health and Social Care Act Code of Practice for health and adult social care on the prevention and control of infections and related guidance from Department of Health

^[20]

In a GP setting a response along the lines of the General note below may be appropriate - though it may be useful to cite the guidance above, and the fee would have to be appropriate to the amount of work requested. In other settings, of course, the response would be simpler - simply to refer the patient back to their employer, citing the guidance above.

Medication in schools and other childcare settings

Guidance has been issued in England^[21] (replacing previous guidance^[22])

Key phrases include:

• Other healthcare professionals, including GPs and paediatricians – should notify the school nurse when a child has been identified as having a medical condition that will require support at school. They may provide advice on developing healthcare plans.(p13 - it is not clear, however, that this is a contractual duty of GPs)
• "Staff must not give prescription medicines or undertake healthcare procedures without appropriate training (updated to reflect any individual healthcare plans). In some cases, written instructions from the parent or on the medication container dispensed by the pharmacist may be considered sufficient, but ultimately this is for the school to decide, having taken into consideration the training requirements as specified in pupils’ individual health care plans." (p15, S27)
• Healthcare professionals, including the school nurse, can provide confirmation of the proficiency of staff in a medical procedure, or in providing medication." (p15, S28)
• "Wherever possible, children should be allowed to carry their own medicines and relevant devices or should be able to access their medicines for self-medication quickly and easily. Children who can take their medicines themselves or manage procedures may require an appropriate level of supervision. If it is not appropriate for a child to self-manage, then relevant staff should help to administer medicines and manage procedures for them." (p15, S33)
• "no child under 16 should be given prescription or non-prescription medicines without their parent’s written consent – except in exceptional circumstances where the medicine has been prescribed to the child without the knowledge of the parents." (p15, S35 - NB it does not say anything about requiring a doctor's note)

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.^[23] 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.^[24]

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:

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:

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

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:

"No: only for part absence and for circumstances you cannot verify. If a medical note is not forthcoming, is there a label from the prescription which can be used or part of a computer prescription sheet? It needs the candidate’s name and the date.

"Please also see the self-certification form and notes for its use ([Form 14 on the JCQ website]). If a candidate misses a unit which can be taken at a later date, please do not ask for a medical note and submit an application. Simply re-enter the candidate at the next available opportunity. Remember to check that the correct preparation has been given for the next series’ unit.

"Please refer to the JCQ booklet ‘Access Arrangements, Reasonable Adjustments and Special Consideration’. This is available on the website."

A more recent version of their guidance is available.^[25]

UPDATE - there is something called a Form 14 self certification form available from the JCQ web site. This has to be signed by a member of the practice staff - not necessarily a doctor.

UPDATE - the references above may no longer be available from the BMA site, but there is still BMA guidance "Supporting pupils with medical conditions at school", relating to DfE guidance on this topic.^[26][27]

In Scotland the Scottish Qualifications Authority guidance states:

If the absence is due to illness, a medical certificate covering the date(s) of absence(s) will be required, unless the illness occurred in school or can be confirmed by letter from the Head of Centre. Please indicate if a medical certificate has been sent to SQA at an earlier date.^[28]

Concessionary bus passes

Councils may provide concessionary bus passes for disabled people. Some of them expect GPs to complete a form or provide a report confirming that a patient is disabled. This is not NHS work and may be declined or charged for. Department of Transport guidance on this states:^[29]

24. Using an applicant's GP to verify that an individual meets the criteria for a concessionary travel pass is regarded as an unsatisfactory arrangement for both the GP and the administrators of the scheme. The main argument against this approach is that it compromises the doctor/patient relationship.

25. The Department strongly recommends that independent health professionals should undertake assessments in place of GPs. In the case of assessment of the inability to walk, for example, occupational therapists or physiotherapists are often best placed to assess eligibility due to their professional knowledge of mobility. Transferring assessment to such specialists implicitly suggests the importance of making judgements based on physical mobility rather than medical conditions.

Fit notes for attending a gymnasium

Many people joining a gymnasium are required to complete a form, declaring any illness. When an illness is declared, they may be required to provide a note from a doctor indemnifying the gym for any medical events that happen while the person is at the gym.

This puts patients in a difficult position. They may well be joining the gym in order to safely exercise, having been told that exercise is good for their health. Clearly, providing such an indemnification for the gym is not NHS work (and therefore could be charged for). Perhaps more importantly, however, it is next to impossible to know whether somebody's medical condition will make them more vulnerable to being harmed by exercise in a gym - other than to say that in most cases the risk is likely to be outweighed by the benefits.

This has been discussed on DNUK, e.g. in a thread started in June, in which various examples of letters used were provided (available only to DNUK members).

"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. Any report that is provided will be considered as an expert witness report: guidance is available regarding what it should contain.^[30]

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 on DNUK (members only) that he issues a standard letter along the following lines when he receives such requests:

Advice for Patients

Sick notes for court appearances etc.

Patients commonly request their GP to provide a "sick notes" to possibly explain why they did not attend, or cannot attend, court.

• Please note that Doctors are not allowed to provide certificates to ‘excuse court attendance’.
• All such requests can ONLY come from the court.
• A statement of fact regarding a present illness can be given but this does not exempt the individual from court attendance. Only the court can sanction this. You must contact the Court immediately and ask for advice.
• A statement of fact cannot be backdated prior to the first recorded date of the doctors consultation about the present illness.
• 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 indeed are themselves at risk of being found to be in contempt of court. GPs will therefore never give certificates in this situation

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

Similar rules apply for patients who want evidence to excuse themselves from jury service,community service, or probation.

See next page for certs confirming attendance at practice. (Page break)

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

(Box for practice stamp marked "Surgery stamp / Certificate invalid unless stamped".)

External Links

• BMA web page "Fees"
• Department for Work and Pensions "Doctors Obligations" document "IB204"^[31]
• 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