Monday, October 13, 2008

Sick notes

Specifically with reference to getting them from hospital doctors. The guidance is available here.

This is NOT a rant against my colleagues in secondary care. Hopefully some of my readers are secondary care docs. Some of them may learn something from this post. Or they may not. (grandmothers, eggs, natch...)

There are 2 main types of sick note patients will come across. The Med3 and, less frequently, the Med5.

The Med3 is the white certificate you might obtain from your GP if you need more than seven consecutive days off work. Its duration can be open (specified typically as "two weeks" for example) or closed (when a specific return to work date is recorded). It cannot be backdated. The patient must be physically seen, in the flesh. Telephone consultations, although they seem to be ignored by the DWP, actually fall outwith the regulations governing these certificates

A Med5 has two possible functions. One is for a doctor to backdate a certificate, but only if he or she has seen you in the recent past and for upto only a month from the date of signing. The other is to provide a certificate (without necessarily seeing a patient) on the basis of a recently received (within a month) letter from another doctor. In this instance, the certificate cannot be backdated (again the DWP seems to ignore breaches when this inevitably happens).

As a GP I do a lot of these.

Not infrequently, patients come to see me after operations or hospital stays to get one because they have not been furbished with one at the time of discharge or they have been given one for a shorter period of time than will obviously be necesary (for example 1-2 weeks after a hysterectomy rather than the 6 weeks virtually everybody needs).

This irritates me. Greatly.

I would imagine it occurs mostly because of ignorance of the regulations by hospital junior doctors. I would hope that it isn't just laziness.

Because you see the guidance is quite clear:

The duty to provide a statement rests with the doctor who has clinical responsibility for the patient at the time. Hospitals are required to provide all certificates for social security and Statutory Sick Pay purposes and doctors' statements for both in-patients and outpatients who are incapable of work. The Med 3 should be issued on discharge from hospital where a hospital doctor advises a patient to refrain from work, and the doctor was attending and had clinical responsibility for the patient at the time this advice was given. In such cases the Med 3 should be issued for an appropriate forward period. Responsibility for issuing further certificates rests with the doctor who assumes clinical responsibility for treating the incapacitating condition. In cases where the GP has not taken over responsibility for the incapacitating condition, responsibility for issuing further certificates will rest with the treating clinician.

I am sure that, at times, junior doctors are advised by others (perhaps administrators or nursing staff on the wards) that sick notes are not available, or that "we haven't got any". It certainly happened to me when I was training.

I have written twice this year to senior colleagues at my local hospital advising of these regulations. The second time I offered to go and do a session at their twice-yearly inductions for the junior doctors. I didn't receive a reply to my second letter, but there you are, some people are just rude. Such is life.

However, given all the problems around the accountability of the GMC (as well as to it) together with increasingly draconian messages regarding probity coming from it, I suspect that in future, I will be regretfully apologising to patients as I do now. But the focus will shift from an apology that my secondary colleagues have somehow abrogated themselves of responsibility for the sick note and provide it whilst steaming quietly in my chair, to apologising that I may not provide a note for them and directing them back to the hospital consultant. I will show them a copy of that paragraph, and will give them a copy to show the consultant.

Hopefully the message will sink in, bit by bit. I will repeat my offer to educate if the opportunity arises (which sadly, I suspect it will). Letters will be written, patients will be inconvenienced.

Does that make me stroppy? I don't think so.


Anonymous said...

You will be sorry to learn that this is news to me and I have been around decades. I think we use Med 10s which you don't mention and are done by nurses.

According to offical documents the Med 3 statement "has been used very rarely in Trusts and in the whole of the NHS generally." Clearly I am not the only one who thought this was the job of GPs.

In fact the Med 10 states at the bottom that "if you are given this on discharge from hospital you will need a fresh sick note within a week from the doctor who is looking after you" which I would have thought in many cases (since hospital follow-up is firmly discouraged) would be the GP. It does not say that the hospital doctor should decide when you should return to work. The implication is that this is the role of the GP (who might well be better placed to decide). The exception to the requirement for a further sick note is when the GP has written a sick note in advance to cover the period in hospital and subsequent recuperation - which seems unusual to me.

I can understand your annoyance and the time this must waste but hospitals are now being forced to discharge patients very quickly. It is just not like you may remember it. For example if we have somebody ready for discharge we are required to move them at once from their bed to a discharge lounge a very considerable distance from the ward so that we can get two patients into a bed in one day. Under this sort of pressure getting the certification right along with a letter for the GP and the TTOs is something of a challenge.

Russell Brown said...

Thanks for the comment.

I think the Med10s are yellow?

If so, as you state they are for the duration of the inpatient stay. The guidance regarding getting another from the doctor looking after you is accurate, but of course refers to the surgeon or physician under whose care they are.

Responsibility does not transfer to the GP at the point of discharge necessarily. Look at the quoted paragraph again: the responsible doctor would be the consultant under whose care the operation or in-patient stay occurred. Not the GP.

Rapid turnarounds are not the point either. Hospital docs have a statutory duty to do these certificates. And the fact that discharge processes make certification difficult are also not an excuse for bad practice (and that isn't directed at you personally). It should be part of the process, not an inconvenient addition. TTO forms and Med3s should be kept together so they can be written at the same time (which also has the advantage that the juniors will have at least some notes available to enter a diagnosis).

Processes should not happen at the expense of patients. Because of course the patient will have the inconvenience of having to see the GP (who is also inconvenienced of course) but additionally the patient may lose benefits or statutory sick pay if certificates are not issued appropriately.

Perhaps you could spread the word.

ageing student said...

When I broke two bones in my foot recently the A&E doctor wrote me a 'standard' (Med 3?) sick note for two weeks. At the end of the two weeks, I popped in to see my GP who obligingly signed me off for another two weeks, although I had a follow-up appointment at the hospital for later in the week. I didn't really think about whose responsibility it was, I just went for the more convenient option.

Russell Brown said...

And quite right too. That I don't mind.

Except, except, except.

You could have been given a sick note to last you until your review appointment, which (if your local A&E does things like mine does) you would gave had in your hand before you left the department.

Same amount of work for the A&E doc. More convenient for you (and your GP, though as I say, no great shakes).

The Shrink said...

I have issued certificates for patients with chronic enduring illness, but as I work mostly with older adults it's mostly a rare issue.

I have had meetings with the LMC who've been very very clear, as you are, that it's not work just to toss to a GP to mop up.

The only other explanation I'd have for why certificates seemingly aren't issued in Secondary Care is that it wasn't thought to be necessary.

When I was in GP land I was equally frustrated by folks seeing me in surgery from hospital discharge, seeking a medical certificate from me. On the one hand, it's easy work in a 10 minute appointment. On the other hand, it's an appointment that shouldn't have been necessary to consume my time or my patient's time.

On challenging Secondary Care medics oevr this it transpired that mostly they were unaware of their obligations. But, sometimes, they'd felt that a certificate wasn't necessary. the patient disagreed so tried to get one from Primary Care.

One colleague felt that Stephen Hawkings can work, then anyone can work. Almost nobody got a Med 3.

But yes, you're quite correct, the rest of the time a mix of ignorance and laziness pervades, methinks.

Pod said...

one poses a problem here, one initially which as a medic you might disagree with the whole profession, but i work in a Podiatric Surgery unit (Foot & Ankle surgery). Unfortunately as were not medics, we cant issue sick notes, even though our patients can often require up to 12 weeks from work

pod said...

thus having to rely on our GP colleagues for support, they (establisment, gov, trust etc) let us perform complex reconstructive surgery but not sign sick notes.

Russell Brown said...

Thanks everyone.

@Pod, actually, the DWP will accept anything from any "health professional", so you could give the patient a note (though not a Med3/5).

However, the Med3/5s are for SSP purposes, and where that is paid by an employer, I can see employers not accepting anything else.

But you sending me people I don't mind, because you're NOT a medic and so CAN'T do these forms for patients.

Anonymous said...

how long would you sign nulabour off sick for?

Russell Brown said...

How long have you got?

dutchdoctor said...

Interesting post. I thought GP's had to sign the sick notes, no one has told me I could do it as well. Never seen any form. I will find out where I can get the forms and what the other consultants do.

smudge said...

My sister recently spend two weeks in hospital as an inpatient. Despite several converstaions with doctors, nurses, ward clerks during that fortnight she was completely unable to get a single sick certificate out of the NHS trust and kept being told her GP would have to give it do her. She had to go and see her GP the week after she was discharged, having been told by the hospital that she should have another week or so recovery before thinking about going back to work, to get a Med3? The pink one anyway and a further Med5 for the following week. She was embarassed about having to ask but fortunately as it's our local NHS trust I guess he's used to it. Needless to say, when she enquiried at her o/p appt just before going back to work about a sick note she was told "go and see your GP".

This is sadly a reflection of the total failure of communication systems within the NHS as even patients who know what they need, are articulate and confident in making their case are unable to get what they are entitled to from hospitals and end up having to waste GP time.

Liza (ex NHS employee)

Anonymous said...

It is the responsibility of the doctor proving the treatment to provide a sick note. It's only more convenient for the patient to attend the GPs surgery if the secondary care clinician doesn't do it.

You don't need a med 10. A med3 or 5 will do.

I saw 4 patients this morning who should have been given a sick note by secondary care.


Anonymous said...

I'd understand if you cannot help with my query but I am struggling to find an answer so thought I'd ask...
I was ill before Christmas and my GP gave me a Med 3.
I gather the "refrain from work" section is usually used for a period, eg 2 weeks, but my doctor completed it with 16th to 24th December 2009, having advised me that I should not return to work until after Christmas (the 29th).
My work have queried the note saying it means I should have returned to work on 24th. The GP's surgery won't amend it because they say there is nothing wrong with it. My mother was a Practice Manager for 17 years and she agrees.
Are there any links / idiot guides / other information on how to interpret a Med 3 that I can give to my employer?

Russell Brown said...

Signing you off till 24th means you could have been available to work from the 24th. Of course it was a long weekend, so if you don't work weekends/bank holidays, then nd result is the same except from a sick pay point of view.

So I can't really answer your question, your employer needs to clarify with your GP. I would suggest they write, enclosing consent from you and they should expect to pay a fee.

Martin Fennell said...

Is it unusual for a GP write a "Open" Med 3 for 12 weeks? and at the same time circle the "will not need to assess your fitness for work again at the end of the period. Condition is Stress.

Regards, Martin F

Martin Fennell said...

I have received a sick note from an employee. "open" Med 3 for 12 weeks with the "will not need to assess your fitness for work again at the end of this period. There is no "to" date filled in. Is this right? Condition is stress. Thank you.

Russell Brown said...

Yes, that doesn't mean you DON'T see your GP, it just means that if you are well enough to go back to work, you don't HAVE to.