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Gold, incentives and meh

Don't be a martyr to those 'doctor's note' requests

Systematically discouraging requests for 'a doctor's note' could save thousands of

GP hours, says Dr Melanie Wynne-Jones

Sometimes it seems patients can do nothing without 'getting a note from their doctor'.

Some requests for notes are legitimate, but many seem to be a cynical attempt to transfer legal liability, or the responsibility for allocating resources (including hospital appointments and operations). Systematically discouraging them could

save thousands of GP hours nationally every week.

Unfortunately many

patients believe that, as the

NHS is free, anything they ask

for should automatically be

granted without cost.

But most of these requests are not NHS services: many are simply try-ons by certain organisations to avoid paying.

GPs are entitled to be paid for their time and practice resources spent on non-GMS work. Not charging undermines colleagues and encourages society to undervalue the profession.

The problem is arguing can take longer

than writing a quick note, and many GPs feel uncomfortable charging patients on low incomes, or threatened by those who get angry.

GP partners can do pro bono work if they wish, but this affects practice profits and not all partners will support this. Salaried GPs and locums should follow practice charging policy which should be explicit and published to patients.

When a note's requested, ask yourself:

lIs a note really needed and can I honestly provide it?

lWhat will happen if I refuse?

lIs the note being given to the patient to pass on, or is it going directly to a third party?

lAre there any potential issues relating to confidentiality, conflict of interest or the Access to Medical Records Act?

lCan I charge, and has the patient/third party confirmed willingness to pay?

lWhat is the most cost-effective way of providing the note? A catch-all proforma/ private sicknote saves both doctor and secretarial time (although it may need to be scanned into the patient's record); a dictation template may improve efficiency.

Notes provided free of charge

lFor the Department of Work and Pensions – Med 3, 4, 5 and 6, attendance allowance, incapacity benefit (IB113) and so on.

lFree prescription certificates for pregnant women, those with exempt conditions,

Mat B1

lTo establish unfitness for jury service

lTo confirm medical entitlement to a postal vote

lTo confirm mental impairment for council tax exemption

lPrivate referral letters

Common requests where a fee

can be charged

lSicknote because employer will not accept self-certification.

lNote to support rehousing on medical grounds – often worth little in comparison with other housing 'points'.

lNote to support fitness to travel or carry out particular activities.

lNote to confirm someone was unwell during an exam or unfit to attend court (I usually write 'Z tells me that.......' where I have no personal knowledge of events, or suggest

that parents pressure school to accept a plaster cast as evidence of Johnny's broken arm).

lSome Government forms including DS1500 and disability living allowance.

lInsurance form confirming private medical referral.

lHoliday cancellation forms

Automatic refusal

I personally refuse to sign anything which:

lI could not stand up in court and honestly defend, although I may write justifiable comments such as 'I was not aware on dd/mm/yy of any reason why X should not travel' (I warn that this may not cut any ice with the patient's insurer).

lProvides a cheap disclaimer for someone selling a service such as eyelash-tinting, body-toning and so on. I tell the patient that the person taking their money is responsible for risk assessment and their safety, but I would be prepared to carry out a private medical if desired (which it never is, once they learn the fee).

lI am not qualified to provide an opinion for, such as fitness to use a treadmill (I can write 'I know of no reason why Y should not use a treadmill', which is true, but not a guarantee).

Charging

Whether the request is made during the consultation, via reception or in writing, sufficient information must be obtained. Also the patient must be informed:

lThat the GP will decide whether the request can be met, and may need to speak to the patient first.

lWhether there will be a charge, what it will be, and who will pay (to be confirmed, or even paid in advance).

lWhen the note will be available.

We attach a pink slip to each request showing the date it was received, when it is needed and which GP should complete it (we hope to computerise this).

The GP annotates this with the date of completion and the fee so the receptionist can charge the patient on collection (showing the practice's published feescale to reluctant payers if necessary).

Audit

The practice should regularly review:

lPolicy and fees.

lIncome from requests for notes.

lNotes requested but not collected to see if payment can be obtained.

lStaff feedback on problems.

Melanie Wynne-Jones is a GP in

Marple, Cheshire

References and resources

•Department of Work and Pensions – Online Learning for Medical Practitioners www.dwp.gov.uk/medical/index.asp

•Fees for Part-Time Medical Services: British Medical Association www.bma.org.uk/ap.nsf/Content/feesparttimemed%5Cgps

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