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At the heart of general practice since 1960

Dubious request for a sicknote

Not all requests for sicknotes are medically justified but some can

be a cry for help ­

Dr Melanie Wynne-Jones suggests ways to

spot them

Sooner or later you will be asked for a sicknote by someone who seems perfectly well enough to work. The doctor-patient relationship is supposed to be based on mutual trust so we don't like it when we feel someone is being economical with the truth.

But deception is not always deliberate ­ patients' opinions and actions may be congruent with their personal view of the world (if not with yours), and some will be suffering from thought disorder.

Some patients seem to take an unusually long time to get over what seem to be minor self-limiting viruses or musculoskeletal complaints. Self-certification for seven days was designed to reduce consultations for these, and frequent minor sickness absences are a matter for the employer, not the GP. Some employers coerce employees into requesting sicknotes for absences of fewer than seven days. This should be resisted, but a private sicknote can be issued for a fee.

Some patients simply lie to their doctors for personal gain ­ to arouse sympathy, manipulate others, obtain medication, take time off work, get out of criminal proceedings or evade other responsibilities. 'Lead-swinging' for longer periods is a problem for the employer, the country and the GP.

Many complaints such as musculoskeletal pain and stress are subjective, and drug and alcohol addiction may not necessarily preclude working. Some stoical patients continue working despite significant suffering and disability, while others seem to have much lower thresholds, preferring to rely on state benefits or to simply try it on.

Form Med 5 can be used for retrospective certification, but do not sign anything you could not justify in court.

The Department of Work and Pensions states that: 'Advice regarding fitness for work is an everyday part of the management of clinical problems, and doctors should always consider carefully whether advice to refrain from work represents the most appropriate clinical management... A doctor is required to record on a medical statement the advice given to the patient regarding their ability to perform their own or usual type of occupation.

'Medical statements are official documents and may be used by a patient as evidence to support a claim to a financial benefit ­ it is therefore very important that statements are completed in accordance with guidance which is based upon the relevant law.'

When your patient is requesting a sicknote, but you suspect they are probably fit to work, you have several options.

1 Challenge/confrontation

This may work, but where a patient complains bitterly about their symptoms there is always the possibility that you may be wrong or at least cannot disprove them; if you and the patient cannot agree, you may find yourself issuing a certificate, albeit reluctantly. Confrontation may also put you at risk of a complaint or even assault, and if your suspicions turn out to be unjustified they could destroy your relationship with the patient. It may be wiser to obtain more information and advice about this patient, their problems and the correct course of action from colleagues or hospital correspondence. (You can still use option 4 if necessary.)

2 Dig deeper

Explore the patient's ideas, concerns and expectations. This may shed unexpected light on the situation, for example by uncovering unsuspected disability, depression, bullying or unsuitable working conditions. Occasionally a patient may be facing disciplinary action and trying to avoid the consequences, or be legitimately stressed if the action is unfair. A sicknote may actually be appropriate; the patient may also need medication, referral to a specialist, a counsellor, occupational health service or their union.

The patient may be willing to consider a graded return to work or light duties, a change of department or line manager, or, if they have musculoskeletal problems, an adjustment to their working environment.

3 Access local services

The Department of Work and Pensions offers a range of local support services to patients who are not working because of a medical condition or disability. These include the Employment Services Disability Service, which may be able to help the patient get back to work with the same employer or to explore alternative employment.

You can ask the service for help in the 'remarks' section when issuing a Med 3, or write to the job centre or employment services office (patient consent is required).

4 Get a second opinion

If you issue a certificate (forms Med 3 or 5) you must enter an accurate diagnosis to enable the Benefits Agency's medical officer to identify patients who may be exempt from the appropriate test of incapacity for work. However, if you feel you need a second opinion regarding the patient's fitness for work you can request this using form RM 7 and send it to the local Benefits Agency office; they will take appropriate action. A copy of form RM 7 is included in each pad of Med 3 and Med 4 statements; it currently does not ask for any clinical information.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Further information

Department of Work and Pensions. Medical Evidence for Statutory Sick Pay, Statutory Maternity Pay and Social Security Incapacity Benefit Purposes: A Guide For Registered Medical Practitioners (2000). Available at www.dwp.gov.uk/medical/

medicalib204/index.asp

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