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Q & A - Certification
Index
CER27 - Homeless person; vulnerability assessment
CER26 - Care home staff medical report
CER25 - Report for the benefits agency
CER24 - Issue of Med 3, 4 or 5
CER23 - Hospital certificates
CER22 - Medical report for appeal against withdrawal of disability living allowance
CER21 - Certificates for optometrists
CER20 - Fit for camping and activities
CER19 - Interval Certificates
CER18 - Duplicate certificates
CER17 - New Ofsted forms and fee
CER16 - Prescribed certificates & private fees
CER15 - Housing association certificates
CER14 - Issuing Med 5 certificates
CER13 - Sickness certificates
CER12 - Care home staff certificate
CER11 - Insurance reports
CER10 - Exam certificates
CER09 - Verification of death
CER08 - Adoption medicals
CER07 - Short terms sickness certification
CER06 - Fitness to travel
CER05 - Fitness certificates
CER04 - Surgery abroad
CER03 - Secondary care certificates
CER02 - Council tax exemption
CER01 - Occupational health
Q CER27 - Homeless person; vulnerability assessment - I have been asked by a housing agency to provide a medical opinion as to the
vulnerability of a homeless patient. The patient cannot afford the fee and I am in any case unhappy to provide an opinion that may be unhelpful to him. What do you suggest? (29/01/04)
Answer - Under the Terms of Service you are not obliged to provide this report, but if you
choose to do so you may charge a fee. Since it is the responsibility of the Housing Agency to make the assessment it is appropriate that they should pay the fee.
If you would be prepared to help with the assessment, we would suggest a letter along the following lines;
Re: Homeless person; vulnerability assessment
Under the 1996 Housing Act, the council has a responsibility to assess vulnerability.
My patient has presented me with a form issued by your office for a
medical assessment. Unfortunately this is not an NHS service and a charge of £XXX would be payable for completion of the form, which the patient is unable to afford.
A doctor has a professional obligation to act
in the patient's best interests. It is therefore impossible to provide a subjective opinion that may be unhelpful to the patient, particularly if the patient is required to pay the fee.
Other housing agencies
get round this problem by making their own assessment of the person's vulnerability. If they require factual medical information to facilitate or support their own assessment, they contact the doctor for the factual
medical information that they require. This request must be accompanied by proof of the patient's valid legal consent to disclosure of this information and an agreement that the agency will pay the doctor's fee for
this service.
If you wish to proceed on this basis I would be happy to oblige.
This has been adapted from a letter sent in by one of our GPs and could be modified for use with any number of similar requests!
CED
Q CER26 - Care home staff medical report - I have received a request for a medical report for one of my patients covering physical and, in
particular, mental fitness to work in a care home. The request states that the patient will have to pay for report. Am I obliged to prepare the report as I find it difficult to charge the patient a realistic fee?
Can I provide a computer printout of the medical records instead?
(14/01/04)
Answer - You are not obliged to provide a medical report and the care
home is not obliged to possess one, unless there are particular concerns. (See Q&A PRA 58)
Patients would be very ill advised to permit their employers access to a copy of their medical records, under any circumstances. This is very
poor occupational health practice and could easily reveal potentially damaging sensitive personal data to an employer who has no right to
that information. As a GP you would also be ill advised to provide a copy of the records for the employer. Doing so could easily result in
litigation if the employer acted upon it with adverse consequences for the patient. This of course would be particularly likely if you did not have explicit legal consent for the disclosure
If you do choose to provide the report you should make sure that you base it on facts recorded in the notes and not opinions that may not be
legally defensible. You must have valid consent and should allow the patient the opportunity to view the report before providing it to the employer. (See Access to Medical Reports Act)
If you have reason to believe that your patient could be placing vulnerable patients at risk, however, you almost certainly have a duty to
inform the appropriate authorities. In these circumstances you should seek specific legal advice from your defence organisation before disclosure.
CED
Q CER25 - Report for the Benefits Agency - I recently refused to provide a report for the Benefits Agency as I did not have my
patient's written consent. When written consent was eventually sent to me it was more than 12 months old. Am I obliged to provide the report? (08/12/03)
Answer - Under the Regulations, NHS GPs are obliged to provide certain
information to a Medical Officer, relating to patients to whom they have issued, or refused to issue, a certificate.
The Regulations state that the doctor may rely on the written assurance from the medical officer, or any officer of the Department of Social
Security, that he holds the patient's written consent, unless the doctor has reason to believe that the patient does not consent.
For consent to be valid the patient must be fully informed about the purpose of the examination and/or disclosure, the extent of the
information to be disclosed and the fact that relevant information cannot be concealed or withheld. Since consent may be withdrawn at any point, it would be wise to check that the patient's consent in this
case is still valid.
Any disclosure must be limited to factual and unbiased information that is relevant to the patient's benefits.
The Access to Medical Reports Act 1988 entitles patients to see reports written about them before they are disclosed. The NHS Regulations state
that, since the Department of Social Security gives all claimants access to reports made in connection with state benefits, it is not necessary to check whether the patient wishes to see the report. However, the GMC
guidance directs that doctors should always check whether patients wish to see their report, unless they have clearly and specifically stated that they do not wish to do so. LMC advice would support this view.
For further information see
GMC publication Confidentiality: Protecting and Providing Information.
CED
Q CER24 - Issue of Med 3, 4 or 5 - Who can issue a med 3, 4 or 5 certificates? Can our practice nurse sign on our behalf? When the
new contract comes in we will probably employ more paramedical staff at the surgery, such as a chiropractor. Will they be able to sign certificates in their own right? (04/12/03)
Answer - The Department of Work and Pensions (DWP) general rules for
the issue of medical statements (Med 3, 4 and 5) state that they must be completed and signed by a doctor, who is defined as a "registered medical practitioner, other than the claimant."
This means that your nurse may not currently sign on your behalf.
In
Reducing General Practitioner Paperwork the government promised that the role of GPs and other health professionals in providing reports
and certificates for employers would be clarified. They stated that, subject to successful pilots, this task would be extended to nurse practitioners by the second half of 2001.
We are unaware of any significant progress on this matter and have contacted the DOH for an update.
We have also asked the DWP whether the "registered doctor" must be registered with the GMC.
In law the title "doctor" is not protected, therefore anyone may claim to be a doctor, although they must not claim to be registered with the GMC.
A chiropractor is therefore legally entitled to call himself a doctor, and may also be registered with his professional body. Whether he would be
permitted to write a med 3, 4 or 5 is not clear. However, the DWP FAQs states clearly that a dentist, who could also claim to be a doctor registered with the Dental Council, may not sign these certificates.
The DWP also clarifies that hospitals are required to provide a Med 3 for an appropriate forward period when a patient is discharged from
hospital, but that responsibility for issuing further certificates rests with the doctor who assumes clinical responsibility for treating the condition.
Footnote 10/12/03
The DWP has confirmed that at present only medical practitioners registered with the GMC, or doctors possessing equivalent EC registration, are legally
permitted to sign or issue official statements (such as Med 3) to patients.
They are aware, however, that other healthcare professionals, including nurses, physiotherapists and osteopaths, already give advice to patients
about: fitness for work; recovery times following operations or procedures; and workplace adjustments or adaptations to support rehabilitation.
The DWP will be running pilots aimed at reducing the burden on GPs, and to ensure that incapacity certification, as far as possible, follows the
patient along his/her healthcare pathway.
The DWP is currently undertaking initial research to explore the feasibility of extending official certification to a wider range of healthcare professionals.
They have already conducted the first two phases of the research which involved a review of existing literature and qualitative interviews with
professionals. The final stage involves quantitative telephone interviews and is due to commence shortly. The findings are likely to be published
in the first half of next year. Decisions will then be made about how to take the proposals forward.
The DOH has confirmed that it is aware that some healthcare professionals other than doctors use and issue their own version of a
fitness for work statement, but states that these must not look like the official form. Chiropractors, osteopaths and physiotherapists in private practice are the major groups who use these forms and the DOH
acknowledges that currently there appears to be little standardisation of guidance or regulation of this practice.
The DOH has confirmed that pilot schemes relating to official certification are currently underway, or due to commence next year,
and that these are expected to report in 2004/05.
CED
Q CER23 - Hospital certificates - Our local hospital is declining to issue certificates following inpatient stays. Could you please let me
have details of the cabinet office edict that says they should do this, so that I may quote the source to the hospital? (27/11/03)
Answer - The document you require is Making a difference - reducing GP paperwork.
The executive summary (page 7 in the web version) clearly states that unnecessary GP input has been, or is being, removed in a number of
areas. Number one on their list was;
"Sick certification will be integrated into the hospital discharge process so that hospital doctors and consultants will not refer patients
to a GP solely for the purpose of obtaining a sickness certificate."
The target date for this was July 2001!
Hospital staff are, therefore, obliged to provide the patient with an adequate certificate to cover the expected period of disability. If the
patient has unexpected complications that necessitate a GP consultation, then it is appropriate for the GP to provide any necessary treatment or
specialist referral and to provide any additional certification that is required. Similarly if the patient's recovery is delayed beyond the expected period then the GP would be obliged to provide further
certification.
You may find
Information for patients being admitted to Hospital a useful leaflet to give to patients before admission to hospital. They will
then know that they have to obtain a certificate before discharge and can show it to any unwilling hospital staff if necessary!
CED
See:
Hospital issue of Med 3's
Q CER22 - Medical report for appeal against withdrawal of disability living allowance - I have a young patient who has been receiving
incapacity benefit. He has recently been declared fit to work and wishes to appeal. He insists that he requires a doctor's letter to confirm his disability. Must I provide this report? (22/10/03)
Answer - Clearly medical evidence will be necessary to determine his
appeal. If the patient requests a medical report to substantiate his claim then you are not obliged to provide it. However, if the National Insurance department dealing with the appeal requests a certificate you
would be obliged to provide it as a prescribed certificate under schedule 9 of NHS the regulations. You may not charge for a prescribed certificate.
Further Information:
Schedule 9 to the NHS (General Medical Services) Regulations 1992: List of prescribed medical certificates
CED
Q CER21 - Certificates for optometrists - Our local optometrists are insisting that patients get a doctor's certificate to confirm that they
have diabetes, before being exempted from paying for an eye test. We have been told that this is a new NHS requirement. Will we also have to confirm a family history of glaucoma where we may well
have no direct evidence in our records? (28/07/03)
Answer - There is no reason to communicate this information to the
optometrist.The patient makes the declaration and the PPSA then carries out a verification check on a representative sample unless they already have the necessary confirmation, such as an exemption from
prescription charges. You should not respond to these queries without good cause.
RIB
Q CER20 - Fit for camping and activities - I am being pressed to supply a doctor's letter stating that a teenager is fit to take part in
activity trips away from home that may include gliding, rock climbing and potholing.
He has a complex psychological history and spent most of his
childhood at a special boarding school as a result. He has been seen very occasionally at the surgery but we do have extensive notes of his medical history and current treatment. I would like to provide a
letter but would like your opinion as to whether this is advisable?
(05/03/03)
Answer - You are of course not obliged to provide the certificate under
your Terms of service and the easy and safe course of action would be to refuse because of the medico-legal risk of providing a certificate. If you choose to help you would have to consider the following points very
carefully because of the potential danger to him or to others.
- You must have the valid legal consent of the patient, if he is competent to give consent, or the parent if not, before disclosing
any clinical details. If he is not competent it is debatable whether he should take part in these activities.
- You could check with him or with his parents whether the youth organisation knows anything of his medical history. If not they
could be taking an unacceptable risk if activities could place him or others at risk.
- You would then need to discuss the risk with the lad and with his parents to ensure that they understand any possible risks.
- You could seek advice from the specialist responsible for his care who should have a thorough understanding of the medical
condition and potential problems in an unfamiliar or dangerous situation. The specialist might be prepared to provide the necessary medical certification.
- Is he capable of taking his medications reliably or could someone supervise this?
- What would be the likely consequences of a failure to take medications reliably?
- If his condition necessitated education in a special school would it be manageable at camp or in an emergency situation.
This situation would have to "managed" in an open and honest way directly between the parents and the youth organisation, on the basis of
evidence from his specialist and/or the school. You or your partners may also be able to contribute to the assessment but you are unlikely to be
able to make this decision alone and should refuse to do so.
CED
Q CER19 - Interval Certificates - I was recently contacted by an insurance company in the middle of surgery for an urgent report
based on a patient's medical history. The patient had been taken ill abroad and the company were refusing to authorise payment until they had seen my report. In this case the patient had no history of
serious illness and I faxed through my report. Was this correct?
(05/03/03)
Answer - The patient accepted the conditions imposed by the insurance
company when he took out travel insurance. If the patient was competent to sign the contract, and did so voluntarily and on the basis of full information, the consent would be legally valid.
However, the patient probably consented only to the company seeking information, and did not necessarily consent to your disclosure of that
data. As a doctor your duty is to provide medical care and to act in your patient's best interests, not to protect insurance company profits. You
should therefore always try to obtain the patient's explicit consent to disclosure if that is possible.
In an emergency disclosure without consent may be permissible. You should seek further information about the patient's medical condition
and the proposed treatment to determine whether or not this is justified by the circumstances. The next of kin may be able to indicate what the patient would wish you to do, but cannot consent on the
patient's behalf.
The Financial Ombudsman's office receives numerous complaints from patients who have gone ahead with expensive treatment that the
insurers have subsequently refused to finance. The ABI and the Ombudsman are clear that an insurance company should warn the patient that they may not meet the claim before he or she incurs considerable
personal expense.
Since the information you provided was likely to support the claim and facilitate urgently required medical treatment, you were probably right
to provide the certificate and probably had a professional duty of care to do so.
If the information was likely to lead to a refusal to pay out, it would have been best to seek the specific approval of your medical defence
organisation before disclosure.
It is of course always important to check that the person and organisation requesting the information is who they claim to be and to
ask them to confirm that they will respect the patient's confidence.
If the data is urgently required by fax, you should ideally anonymise it and fax the patient's identity separately. The recipient should be asked
to wait by the fax machine and acknowledge safe receipt of the data.
You are not bound by your Terms of Service to provide interval certificates and are entitled to a fee if you choose to do so.
Further information:
See Guidance on "Interval" or "Duration" certificates
Q CER18 - Duplicate certificates - I am often asked for duplicate sick certificates from patients who have either lost them, whose
employers have lost them, who say that the Benefits agency have lost them, or who claim their employer insists on another copy when the original has been sent to the Benefits Agency. Since this seems to be
a growing problem, can we charge for issuing a duplicate?
(20/02/03)
Answer - The rules state that a certificate must be:
- issued once - any replacement certificate which may be required if the original is lost should be clearly marked 'duplicate' and should
be provided by the practitioner who issued the original certificate
- for Social Security purposes only - do not use the prescribed certificates for anything other than Statutory Sick Pay or Social
Security benefit purposes
You should not provide a duplicate for the employer if the original has been sent to the Benefits Agency. You may choose to provide a private
certificate to verify the medical problem and make a charge.
Schedule 9 of the TOS prohibits charging for any of the prescribed medical certificates so you may not charge for a duplicate.
The Department for Work and Pensions guidance provides further authoritative advice on certification.
Also DWP Q&As on certification
CED
Q CER17 - New Ofsted forms and fee - I believe that there is a new Ofsted medical report form for prospective child carers. Does Ofsted
now pay any fee that is due as it is always difficult asking a poorly paid person to pay for a private medical report? (15/01/03)
Answer - Under the Children Act 1989 Ofsted has a statutory duty for
the registration and inspection of care for children under the age of 8. The BMA and OFSTED have recently agreed on a revised health declaration booklet for childminding applicants. The revised booklet
makes it clear that the applicant must pay any fee that his or her doctor requires for this service. The BMA's suggested fee for GPs completing this form is £60.00 (based on an average of 35 minutes to complete the
form).
The new form requires the patient to complete a health declaration. In the case of a fit patient the doctor is then only required to validate the
patient's declaration, based upon information in the medical records. This should be a relatively quick and simple matter, unless the patient has medical problems that would require greater input from the GP. The
intention is that this new procedure should dramatically reduce the burden on GPs.
In response to concerns that we raised with Ofsted, we have received assurances that in the new system the patient consents to completion of
the form on the basis of full information. In addition they are informed of their rights under the Access to Medical Reports Act. The completed forms should be returned to the Medical Adviser and we have been
assured that they will in future be handled according to a strict protocol to ensure confidentiality.
It is still a bone of contention that the patient is responsible for paying the fee for this medical report before being eligible for what is
generally rather low paid employment. However, it seems very unlikely that this situation will change in the near future.
CED
Q CER16 - Prescribed certificates & private fees - What certificates am I obliged to provide free and how do I determine the fees to
charge for other reports? (30/12/02)
Answer - Schedule 9 of the Terms of Service
sets out which certificates you are obliged to provide free of charge. For any other
certificate or report you may charge an appropriate fee.
The BMA provides guidance on fees for insurance reports and other private fees. The Medeconomics magazine provides a comprehensive UK
Database of recommended rates for various professional services. GPs may log into the GP online web site to access this database.
It is important to remember that the fees recommended are only recommendations and in no way binding.
CED
Q CER15 - Housing association certificates - I have been asked to provide a certificate to a Housing Association stating that one of my
patients is fit to accept young people as lodgers who may have been in Local Authority Care previously. Is this within a GP's sphere of expertise and if I do provide the certificate can I charge the patient?
I have been sent a consent form, signed by the patient, that states that such a certificate is necessary in order to become a registered householder under the Housing Association's lodgings scheme. I have
been asked to return the certificate direct to the Housing Association. (14/10/02)
Answer - This is not required by your Terms of Service and if you do
choose to provide the certificate you are entitled to charge the patient.
The decision as to whether it is within your area of expertise is really for you to determine. If you decide you are competent to provide such a
certificate you should base it on facts, or lack of them, as documented in the notes, rather than opinions that may be open to challenge.
The consent states that such a certificate is necessary in order to become a registered householder under the lodgings scheme. There is
therefore a degree of duress. In addition you have no way of knowing if the patient has been fully informed as to the ways in which the information will be held and used. Either of these points could render
the consent to disclosure invalid. You should therefore provide any certificate direct to the patient and not to the Housing Association. If
the patient agrees to release the certificate to the association it is their decision and would not involve any breach of confidence on your part.
You would be wise to add on the form words to the effect that your certificate is based on a review of the notes and/or your knowledge of
the patient. If the patient was a paedophile, or there was some other reason rendering them unsuitable, you would not necessarily have any knowledge of this and your certificate should reflect this understanding.
CED
Q CER14 - Issuing Med 5 certificates - I have been signing long-term sickness certificates for a patient who recently came in late for this
routine certification. Can I issue a Med 5 certificate? (25/09/02)
Answer - The following extract is taken from the Department of Work
and Pensions guidance on certification.
"When issuing a Med 5 statement you must:
- base your advice on your examination of the patient on a previous occasion
- be sure that you would have advised the patient to refrain from work from the date of examination for the entire period of the certificate.
The only exception is where the certifying doctor has a report from another doctor. You may use this evidence to support an opinion that
your patient is incapable of work providing:
- the report was issued less than one month previously
- the certificate you issue does not cover a forward period of more than one month.
Background notes
Certifying doctors can only advise a patient that they would have been
medically incapable of work for a past period in circumstances where it would have been appropriate to give such advice prospectively. Unless there is clear evidence available to the doctor to support the advice,
for example clinical notes based on a previous examination of the patient, it is unlikely that the doctor will be in a position to provide such advice. The period of incapacity advised by the doctor should be
fully in keeping with the clinical findings at the onset of the period of incapacity."
We checked this out with a doctor working for the department. He clarified that you may give a Med 5 if you have been seeing the patient
regularly and know that, on the basis of your previous knowledge, you would have given a prospective certificate to cover the entire period in question.
If in doubt about any individual case it would be wise to confirm the details with the local Benefits Agency.
CED
Q CER13 - Sickness certificates - Please can you give me some advice or documentation for sick notes, Med3 and Med5's? I find it difficult
to know how much flexibility I have in this respect. It is a weekly problem as I work with the homeless who often find it difficult to attend appointments when they are ill. (25/09/02)
Answer - It is important to be very strict in applying the rules as you are
signing a legal document and putting your professional reputation on the line. Unless you see the patient at the time of an illness it is impossible
to be absolutely sure that he or she has in fact been ill. Effectively you could easily be contributing to a fraudulent application for State benefits.
If your patients have problems obtaining legitimate benefits they should take the matter up directly with the Benefits Agency.
The Department for Work and Pensions Office has produced some very useful guidance on medical certification. This gives very specific advice and may be found at: www.dwp.gov.uk/medical/medicalib204/content.asp
In my experience the department is very helpful in clarifying and confirming queries that are not fully answered by the guidance. For
example they were able to confirm the rules concerned in an interesting exception to the restriction on providing short term certificates in the case of a second illness of less than a week, with total incapacity of
more than 7 days, within an 8-week period.
See Related Q&A - CER07
CED
Q CER12 - Care home staff certificate - I have been handed a memo by a patient that has been issued to all staff at a local care home.
The patient tells me that the law requires me to provide her with a certificate that she is mentally and physically fit to work in the home. Is this correct? (01/07/02)
Answer - Schedule 2 of The Care Homes Regulations 2001 requires the
nursing home to hold a number of documents for all staff working in the Home. This includes "evidence that the person is physically and mentally fit for the purposes of the work which he is to perform at the
care home or, where it is impracticable for the person to obtain such evidence, a declaration signed by the person that he is so fit."
The Terms of Service do not require you to provide this evidence. If you do choose to provide such a certificate then you may charge a fee.
However, if you refuse, the schedule allows the patient to self certify that he or she is fit.
CED
Q CER11 - Insurance reports - the BMA has recently struck a deal with Insurance companies for a £54 fee for medical reports. In the
absence of an agreed rate we have recently been charging and getting higher fees that we believe reflect the amount of work required more accurately. Are we obliged to stick to the new agreed
fees?
(26/06/02)
Answer - The fees agreed represent a level that the BMA and the
Insurers considered a fair charge for the work required and may simplify your administrative procedures. It is however only a recommendation and you are entitled to charge whatever you choose for this work. If you
wish to determine your own scale of fees, however, the Insurance companies are likely to be reluctant to pay more than the BMA agreed fee and this could cause you considerable difficulties in securing
payment of your fees. If you believe it is worth sticking out for higher fees this is your decision.
Q&A
PRA 08 contains suggestions on fee determination if you should take this decision.
Further Information:
Medeconomics private and professional fee database
(must log in to access database)
CED
Q CER10 - Exam certificates - At this time of year we usually get a number of requests for certificates relating to illness that may have
had an adverse effect on a patient's exam performance. Do we have to provide certificates and are these really taken into account?
(10/06/02)
Answer - It is not part of your Terms of Service to provide a certificate,
but you may provide a private certificate if you know of a medical problem that may have had an adverse effect at the time of the exam performance. Now that so much of an exam result depends upon course
work there are in addition a number of medical problems that may impair performance over a prolonged period prior to the final exam.
If a student believes that they have performed badly a medical certificate may seem an easy way of damage limitation. This places the
doctor in a difficult situation. You should not give a medical certificate based on hearsay unless you have good reason to believe it to be true.
The Joint Council for General Qualifications may take medical conditions into account when considering the grades awarded to an individual candidate.
We have received this advice and clarification of the certification
requirements from them.
Exams are enormously stressful for students and parents and doctors are advised to use their judgement at all times. We are working to establish
clear guidelines that are acceptable to local schools, the exam boards and to the medical profession.
Further information;
on special considerations is available in the Joint Council for General
Qualifications - Regulations and Guidance relating to Candidates with Particular Requirements.
LMC guidance on Certificates for school children at exam time
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Q CER09 - Verification of death - We have had a problem recently as the local OOH Co-op refuses to visits patients who have died in a
nursing or care home. At weekends and over extended bank holiday periods this can cause problems. Either the body remains at the home for an extended period, which is neither practical nor
acceptable, or the body is transferred to an undertaker's premises that may be many miles away. This creates a problem for the regular GP who has to view the body before issuing a death certificate. How
should we resolve this issue? (29/05/02)
Answer - Any competent person may verify the fact of death in English
law and most undertakers are prepared to remove a body from a nursing home once death has been verified, provided the death was expected and there are no suspicious circumstances. There is no necessity for
any doctor to attend to verify the fact of death.
Occasionally if the death has caused significant distress to friends, relatives and carers it may be professionally and ethically reasonable for
a doctor to attend out of hours to verify the fact of death.
If the death is unexpected then a doctor may be required to attend as soon as the needs of living patients allows. An undertaker may well not
be prepared to remove the body in these circumstances until a doctor has attended.
If the death occurs at night, it would seem generally acceptable during the week for the regular GP to attend as soon as possible next day, if it
is required, and is a sufficiently speedy response.
However, in cases where the death was not expected, there could be occasions over a weekend or holiday period when the regular GP is
unable to attend next day. Leaving the body at the home for several days would clearly be unacceptable and is generally unnecessary. If there are no suspicious circumstances the undertaker should arrange for the
body to be removed.
However, if an OOH death is suspicious, particularly if the police or ambulance services are involved, then the services of a doctor may be
required urgently. In this situation a police surgeon should generally be called. A Co-op OOH doctor is unlikely to have any forensic training and
must in any case attend to the needs of living patients as a priority.
It is not essential to see the body before signing a death certificate,
provided the fact of death has been verified and there is no question that the patient is definitely dead and there are no suspicious circumstances. When the death was expected the regular doctor should
generally be able to sign a death certificate without seeing the body, so removal of the body to premises many miles a way should not present a problem.
It is, however, essential to examine the body before signing a cremation certificate. In this situation removal of the body can cause
problems for the regular GP who may have to travel many miles to carry out the examination.
The most convenient and effective local solution is generally achieved as a result of good communications and co-operation between local GPs,
nursing and care homes and the local Co-op or deputising service.
The subject of verification and certification of death causes considerable problems for GPs and the GPC have produced some very helpful guidance on Confirmation and certification of death.
Further Information
Guidance from Devon LMC on verification & certification of death
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Q CER08 - Adoption medicals - Could you help me with this information please? Are we obliged to carry out adoption medical
examinations, and if so what fee can we charge, if any?
Updated 04/06
Answer - This has been a matter of considerable dispute. However, there is no requirement
under the Terms of Service to carry out adoption medicals .
You may, however, choose to provide this service under the NHS as part of the Collaborative Arrangements. The statutory basis for these
arrangements is contained in 26(3) c of the NHS Act 1977.
26 (3) The Secretary of State shall make available to local authorities-
(c) the services of any medical practitioner, dental practitioner or
nurse employed by the Secretary of State or a health authority otherwise than to provide services which are part of the Health service,
so far as it is reasonably necessary and practicable to enable local
authorities to discharge their functions relating to social services, education and public health.
These fees are set under the collaborative arrangements by the DDRB each year and are paid by the PCT on behalf of the Social Services.
These are not negotiable, unlike fees for insurance medicals.
The current fees, until the next revision in 2004, are set out in Advance letter (MD) 2/03.** The fee for a detailed medical examination and
report on a child, in a form recommended by the British Association for Adoption and Fostering (BAAF), is now £94.85 and the fee for a health
assessment of a prospective carer is now £71.55. These increased fees are applicable from April 1st 2003. (In the past fees have always been increased on 1st July.)
However, Wessex LMCS takes the view that, since there is no obligation to perform these medicals under the collaborative arrangements, you
may choose to offer the service privately. In this case you must make this plain to the patient, and you should agree the fee and responsibility for payment, before performing the medical.
** Advance Letter (MD) 2/04
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Q CER07 - Short terms sickness certification - We were wondering if there are any circumstances where we are obliged to provide a Med
3 certificate for illnesses of less than 7 days duration? We are particularly interested in the situation where someone is on probation/doing community service/on benefits as we have had a
number of requests recently. (13/05/02)
Answer - You must not provide a Med 3 for any purpose other than a Benefit application.
In general you are not obliged to provide a Med 3 certificate for any illness of less than 7 days duration.
However, according to DSS regulations two spells of incapacity totalling more than 7 days in any 8-week period may be linked for the purpose of
claiming benefit. The doctor may therefore be asked to provide a Med 3 certificate for the purposes of a benefit claim on the 8th day of
incapacity. This could therefore, under the benefit regulations, be after a second spell of incapacity lasting less than 7 days.
The Terms of Service state that; "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."
Schedule 9 of the General Medical Services Regulations describes a
"medical certificate" to "support a claim to prove inability to work or incapacity for self support for the purposes of an award by the Secretary of State."
It seems likely that in these particular circumstances the doctor would be legally required to provide a certificate.
Further information
Department for Work and Pensions; A Guide for Registered Medical Practitioners
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Q CER06 - Fitness to travel - I am getting more and more requests for certificates of fitness to travel. I know that I can charge for these,
but they are taking up more and more of my time. I also know that they are not prescribed certificate under the Terms of Service and that I can refuse to provide them. However, if I refuse this places
patients in a very difficult position and may mean that the airline or travel operator will refuse to allow them to travel. What do you advise? (02/05/02)
Answer - We are not aware of a specific increase in letters on fitness to
travel, but GPs are increasingly being approached for all sorts of certificates for medico-legal reasons! The recent publicity surrounding Deep Vein Thrombosis and Pulmonary Embolus as a result of "economy
class syndrome" and the increasing number of people travelling abroad has probably caused travel operators and airlines to operate a damage limitation exercise whereby they can spread the risk.
There is a problem for your patients if you refuse to provide a certificate, but equally there is a problem for you if you certify a
patient is fit to travel who subsequently develops a medical problem. Even if you carry out a thorough history, examination and any necessary
investigations you can still offer no guarantee that the patient is fit to travel. This can present problems even in an apparently young fit person,
but problems are even more likely if the patient is old, very young, pregnant or has a pre-existing medical condition.
LMC advice would be to provide a certificate with words to the effect that "based on information available in the medical notes the patient
appears to be fit to travel, although it is impossible to guarantee this." If you choose to carry out a medical examination you should still add a similar disclaimer to your decision regarding fitness.
You may wish to seek the legal advice of your medical defence organisation regarding the most suitable form of words in the interests
of your own risk management and damage limitation policy!
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Q CER05 - Fitness certificates - We have had a number of patients recently who have been asked to provide a certificate to prove that
they are fit to run a marathon. I am worried about providing these.
What is your advice? (22/04/02)
Answer - This is a difficult situation in which the marathon organisers
are seeking to protect themselves from any subsequent litigation.
This is not a prescribed certificate and therefore you are not obliged to provide it. If you choose to do so you may charge a fee.
Although the patient may appear young and fit with no obvious medical problem it is impossible on the basis of even the most comprehensive
medical examination to guarantee fitness. It is not unknown for sportsmen and women, who are apparently very fit, to experience serious medical problems, including sudden death, in the course of
strenuous physical activity.
LMC advice would be to provide a certificate with words to the effect that "based on information available in the medical notes the patient
appears to be fit to take part, although it is impossible to guarantee this." If you choose to carry out a medical examination you should also add a suitable disclaimer to your decision regarding fitness.
You may wish to seek the legal advice of your medical defence organisation regarding the most suitable form of words.
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Q CER04 - Surgery abroad - Several of my patients are travelling to Germany for surgery funded by the PCT in an attempt to reduce the
waiting list. I have been asked to fax to the PCT a form certifying the patients' fitness to travel and ability to walk 200 metres. I am also asked to give my consent to the transfer of care to the German
surgeon. I have some serious concerns about this, what do you think about it? (18/04/02)
Answer - The surgeon who has assessed the patient for surgery should
ideally make the decision about fitness to travel pre and post-operatively, based upon the patient's medical history, knowledge of the procedure to be carried out and any relevant details included in
the referral letter.
We have taken GPC advice about filling in the fitness to travel question on the form. They have suggested that you add a disclaimer to the form
along the lines that "nothing in the medical records indicates that the patient is unfit to travel"
With regard to transfer of care to the German surgeon, as the patient's GP it is difficult for you to know exactly what surgical procedure is
planned. It is also difficult for you to assess the competence of the surgeon and his team to carry out the proposed surgery and to provide
adequate pre and post-operative care. Again a disclaimer to the effect "I consent to the transfer of care provided that the PCT have taken all
necessary steps to ensure that the surgeon and his team are competent to perform the proposed surgical procedure and provide adequate pre and post-op care."
Before consenting to the transfer of patient care to a surgeon abroad you may also wish to satisfy yourself that the PCT has taken out appropriate
insurance cover in the event of complications arising. You may wish to add a clause relating to this in your disclaimer.
The GPC have passed on your concerns to the Department of Health and, until definitive advice is available, advise GPs to check the wording of
any disclaimer with their own defence organisation.
If time does not allow for the certificate to be sent by post or collected by the patient, sensitive patient-identifiable data may only be faxed using a
Safe Haven procedure.
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Q CER03 - Secondary care certificates - A patient came to see me today saying she had hysterectomy and bladder repair done 2 weeks
ago. She was given a certificate for 2 weeks and told to get further certificates from me. This is plainly ridiculous. What should I do?
(15/04/02)
Answer - We agree and for once the government agrees with us! The
government set out clearly defined targets for reducing some of the bureaucratic demands in general practice in the document Reducing General Practitioner Paperwork.
All hospital trusts are supposed to have had proper sickness certification procedures in place since July 2001 ensuring that patients are no longer
referred to the GP following hospital discharge for the sole purpose of obtaining a sickness certificate.
I suggest that you write to the consultant concerned using the attached template. If this problem occurs regularly and is not being adequately
addressed you may wish to copy your letter to the Chief Executive.
Sample template letter
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Q CER02 - Council tax exemption - I have been asked to provide a certificate for the purpose of claiming exemption from council tax
stating that one of my patients suffers from severe mental impairment . Am I obliged to provide this and if so may I charge a fee? What is the official definition of severe mental impairment?
(11/04/02)
Answer - Schedule 9 of the NHS (GMS) Regulations requires you to fill in
this form without charge.
(The schedule of prescribed certificates is available in Medical reports access and charging )
You may well be able to complete the form without seeing the patient.
Section 1 of the Mental Health Act provides the following definition;
Severe Mental Impairment...
... means a state of arrested or incomplete development of mind which includes severe impairment of intelligence and social functioning and is
associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned
For the patient to claim exemption you must certify that in your opinion he or she is suffering from severe mental impairment within the
meaning of Schedule 1(2) of the Local Government Finance Act 1992.
The following notes may prove helpful;
Council Tax - Discounted Persons Class 4 "Severely Mentally Impaired" or Exemption Class U
The Council will not include such persons as described below for Council Tax purposes:
A person (aged at least 18 years of age) whose sole or main residence is normally the property and who has a severe impairment of intelligence
and social functioning which appears to be permanent and is entitled to receive at least one of the qualifying benefits listed below:
- incapacity benefit under Section 33, 40 or 41 of the Social Security Contributions and Benefits Act 1992;
- an attendance allowance under Section 64 of that Act;
- a severe disablement allowance under Section 68 of that Act;
- the care component of a disability living allowance under Section 71 of that Act, payable at the highest rate under Section 72(4)(a)
or at the middle rate under Section 72(4)(b) of that Act;
- an increase in the rate of disablement pensions under section 104 of that Act (increase where constant attendance needed);
- a disability working allowance under Section 129 of that Act for which the qualifying benefit is one falling within subsection
(2)(a)(i) or (ii) of that section, or is a corresponding Northern Ireland benefit;
- an unemployability supplement under Part 1 of Schedule 7 to that Act;
- a constant attendance allowance under:
- article 14 of the Personal Injuries (Civilians) Scheme 1983: or
- article 14 of the Naval, Military and Air Forces etc. (Disablement & Death) Service Pensions Order 1983 (including
that provision as applied, whether with or without modifications, by any other instrument);
- an unemployment allowance under article 18(1) of the Personal Injuries (Civilians) Scheme 1983, or article 18(1) of the Naval,
Military and Air Forces etc. (Disablement & Death) Service Pensions Order 1983 (including that provision as applied, whether with or without modifications, by any other instrument).
The appropriate legislation for the discount is "The Local Government Finance Act 1992 Schedule 1(2)", for the exemption "The Council Tax
(Exempt Dwellings) Order 1992 SI1992 no 558 (as amended)".
A patient who is severely mentally disabled will normally be given 100% exemption from Council tax, provided that the property is his or her
sole or main residence. If it is shared with others they must also be severely mentally impaired or receiving at least one of the above allowances/benefits.
The exemption will generally apply for as long as the circumstances remain the same and the Council may, from time to time, check that there has been no change.
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Q CER01 - Occupational health - I have given a patient a certificate to return to work but the employer wants me to sign her off until the
Occupational Health Physician (OHP) agrees she is fit. (21/03/02)
Answer - Fitness to work is a matter of medical opinion and you must only ever give YOUR
opinion. You are obliged to record this on a Med3 certificate. You should never give an opinion just because another doctor tells you to! It is your professional judgement that could be
called into question.
It is wise to discuss the nature of the job to be sure that the patient really is fit to do it. With the patient's valid consent you may wish to
discuss this with the OHP if you are unsure. It is better to have a professional agreement than a dispute that could end with one or other doctor in court!
If the employer chooses not to allow the patient to resume work then the employer must pay him or her to stay off work.
If the company needs a report on the patient's condition, this is NOT part of your Terms of Service. If the patient gives valid, fully informed
consent you may provide a confidential medical report with X-ray findings, lab reports etc to the OHP to help him form a proper opinion. Your report must not be revealed to the employer.
You may obviously charge a private fee for this.
LMC Guidance;
Occupational Health
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