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Should you certify patients fit for purpose?

Dr Michael Devlin of the MDU advises on the often tricky problem of certifying patients as being fit

for various activities

Patient certificates, for example, where a GP is asked to certify a patient fit for a particular activity or indeed sick and not able to work, are a frequent cause of calls to the MDU's medicolegal advice line.

GPs can be asked to certify patients fit for all kinds of activities, such as potentially risky holiday sports like scuba diving, leisure activities such as therapeutic massages and even school plays. GPs ask if they are obliged to complete such certificates, and ask about the medicolegal considerations.

In such situations it is advisable for GPs to know something of the activity they are certifying the patient fit for and be as satisfied as they can be that any health problems the patient has, such as obesity or diabetes, will not be exacerbated by the activity.

This is reflected in GMC advice. In paragraphs 63 and 65 of Good Medical Practice (2006) it states: 'You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must do your best to make sure any documents you write or sign are not false or misleading. This means you must take reasonable steps to verify the information in the documents, and that you must not deliberately leave out relevant information.'

It is the MDU's advice that where a doctor completes a 'fit for' certificate it is phrased to reflect an opinion within the doctor's competence. For this reason, we suggest doctors wishing to sign certificates consider carefully the wording they employ.

For example, rather than signing to say patients are fit to take part in particular activities, doctors may decide to say they 'know of no reason why the patient should not be fit for' the particular activity provided that the signing doctor has sufficient knowledge of that activity to be able to make that judgment.

Dilemmas can also arise when patients request sickness certificates. A common scenario is when GPs are asked to write vague diagnoses on sick certificates because a patient does not want their employer to know the illness they are suffering from. For example a GP might be asked not to record that the patient's diagnosis is depression.

Unlike 'fitness certificates' GPs are contractually required to issue various 'prescribed medical certificates' including sickness certificates for illnesses of more than seven days.

The GMC's guidance on signing documents above applies, and GPs should also be aware of, and guided by, the booklet 'Medical evidence for statutory sick pay, statutory maternity pay and social security incapacity benefit purposes: a guide for registered medical practitioners (IB204) (August 2004)', available from the Benefits Agency1.

There are four common sickness certificates: Med3, Med4, Med5 and Med6. GPs are probably most familiar with Med3 – which states that the doctor examined the patient 'today/yesterday' – and Med5, which allows for the provision of a certificate where the patient has been seen for the illness previously2.

The guidance from the Department of Work and Pensions referred to above makes clear that an accurate diagnosis must be provided on sickness certificates; terms that do not relate to a specific disease or disablement should not be used. However, the guidance accepts that there may be circumstances in which a doctor feels it could be prejudicial to a patient's well-being to give a precise diagnosis and so the patient's employer should not be informed of it.

In such circumstances, the doctor is required to issue a form Med6 at the same time as completing the sickness certificate. The Med6 goes to the Department of Work and Pensions, which will then write to the GP for a report, including the precise diagnosis.

Providing certificates may be a routine administrative task, but it is important that completed forms are accurate and accord with GMC guidance.

There are potential pitfalls in providing both fitness certificates and sickness certificates to patients, and members are encouraged to seek advice from the MDU in complex cases, ideally before completing such forms.

Case example

A mother and son asked a GP to provide a certificate saying the child was fit to participate in a school activity trip which would involve sports such as canoeing, scuba diving and waterskiing. The GP was concerned about issuing the certificate as the child had asthma, which the GP felt could be exacerbated by some of the sports.

When he explained this to the mother she became upset and pleaded with the GP to issue the certificate as she thought her son could be bullied by some of the other children if he was excluded from some of the sports. The GP wondered what he should do and rang the MDU for advice.

The MDU adviser drew the GP's attention to the GMC's guidance and advised that the GP must, in accordance with Good Medical Practice, be honest and trustworthy in providing a report. If the GP believed the existence of asthma would affect the child's fitness to undertake certain activities then there was a clear ethical obligation to detail this on any certificate.

Where the mother or child could not accept the advice being given by the GP, it would be reasonable to offer them a second opinion, for example, the GP could refer the patient to a colleague or to a specialist. Although the mother's concerns were understandable, the GP could not provide a certificate that was false.

The GP explained to the mother that he was unhappy to provide a certificate. The mother ultimately accepted the GP's advice and she later reported that the child participated as fully as he was able in the school trip, which he enjoyed thoroughly.

Michael Devlin is an MDU medicolegal adviser

The case mentioned is fictitious, but based on cases from the MDU's files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.

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