Sickness Certification in Primary Care

Although usually straightforward, the provision of certificates for patients may sometimes cause difficulty. A full and detailed guide to the provision of certificates by medical practitioners is provided by the Department for Work and Pensions (DWP).¹

An employer may require an employee to provide a doctor's certificate after more than seven days' sickness.

• An SC2 self-certification form (SC1 for unemployed or self-employed) is used by an employee to provide their employer with details of sick absences of 4 or more days in a row. The completed SC2 form is then used to help decide whether or not the employee is entitled to receive Statutory Sick Pay (SSP).
• GPs are not obliged to issue NHS medical certificates for periods of sickness of less than seven days' duration. However, if a patient requires a short-term certificate, the GP is entitled to charge a fee. However, it is clearly not an appropriate use of NHS time to see patients for no other purpose than to provide a sick certificate.
• Some employers continue to operate occupational sick pay schemes which offer employees more benefits than those laid down under SSP legislation but require certificates for short periods of sickness. Standard disciplinary procedures recommended by ACAS provide employers with the means for dealing with employees suspected of abusing the privilege of self-certification, or who have a record of persistent short-term sickness absence.
• There have been various guidelines provided to deal with these problems. Employers can be informed that, if they require additional certification, then they should make their own arrangements with a doctor on a private basis to assess and verify the the patient's illness and consequent sickness absence.

• The appropriate forms should be:
  • Completed in ink
  • Signed by a registered medical practitioner (other than the claimant)
  • Issued only once
  • Provided for Social Security purposes only
  • Kept secure to prevent misuse and fraud
• The form should contain details of:
  • The patient's name
  • An accurate diagnosis
  • The date the statement is issued
  • The address of the doctor
  • The doctor's signature
• Duplicate statements:
  • Can only be issued when the original statement has been lost and should be clearly marked 'duplicate'
  • People with more than one employer should be advised to submit the certificate to their main employer, who can note the details of the advice you have given, and then present the certificate to their second employer

• A Med 3 is generally required after 7 days of incapacity.
• If the patient is claiming a state incapacity benefit and has had short spells of incapacity totalling more than seven days within an eight week period, a Med 3 may be required for periods of incapacity fewer than seven days.
• A Med 3 can only be issued within 24 hours of examination by the doctor who signs the certificate. However, a comment in the 'remarks' section such as 'patient tells me he/she has been unfit since...' may be appropriate if the patient has already been unable to work for longer than seven days.
• Periods of incapacity can be indicated in two ways:
  • Open certificates:
    • If unable or do not want to specify a date for return to work, then complete the 'for' section.
    • Can only initially issue a Med 3 certificate for up to one month.
    • Cannot issue a Med 3 certificate for more than 6 months within the first 6 months of incapacity.
    • After the first 6 months of incapacity, can issue a Med 3 certificate for any clinically appropriate period up to indefinite.
  • Closed certificates:
    • When able to give a specific date for a return to work, complete the 'until' section.
    • The specific date may be up to 14 days after the date that the statement is issued.
• The 'remarks' section can be used to advise the patient if they are able to work but with restrictions ('light duties') or whether a workplace assessment by their employer might be appropriate.
• If the patient has been found capable of work, a Med 3 will not be appropriate for that spell of incapacity unless the condition has deteriorated or changed significantly since the assessment. (Give details of reasons in the 'remarks' section of the Med 3.)

The Med 5 certificate is used for:

• Covering an earlier period:
  • Based on examination by another doctor. Where you have a report or records from another doctor to support an opinion that the patient is incapable of work, providing the report was made/issued less than one month previously
  • If the opinion is based on evidence other than your own examination, the certificate must not cover a forward period of more than one month
• Based on your examination:
  • This may be required if the patient is off work for longer than initially anticipated, e.g. told to use self-certification form but genuinely unable to return to work for 2 weeks
  • The advice must be based on your examination of the patient on a previous occasion
  • The doctor must be sure that they would have advised the patient to refrain from work from the date of examination for the entire period of the certificate

• A fully completed Med 4 can:
  • Identify those people with a severe condition who may be 'exempt' from the Personal Capability Assessment (PCA), which is:
    • The procedure used by Jobcentre Plus to determine whether a patient should continue to receive a state incapacity benefit or equivalent benefit.
    • The PCA applies from the start of a period of incapacity if the patient has not worked for at least eight weeks in the preceding 20 weeks.
    • In all other cases the PCA is applicable from the 29th week of incapacity.
    • The medical advice is provided by a doctor approved by the Secretary of State.
  • Avoid the need for the patient to be called to a medical examination when their own doctor's medical evidence provides sufficient information for the approved doctor
  • Reduce the need for medical evidence in the event of an appeal against disallowance of benefit
• The patient's GP may be requested to provide a Med 4 statement prior to the first application of the PCA.
• The patient's GP is not required to read or comment on the patient's questionnaire that has been requested by the Department.
• The patient must be examined on the same day or the day before the issue of a Med 4 statement.
• The completed form should include details of an accurate diagnosis of the main incapacitating condition and other relevant medical conditions.
• In the final section of the Med 4, advice about return to work should be recorded in the same way as with the completion of a Med 3.
• Even though the PCA process has commenced, the GP can still advise the patient that they are fit to return to work to end the current spell of incapacity.
• The advice provided on a Med 4 about incapacity for work overrides the advice provided on any earlier statement, Med 3 or Med 5.
• Using the 'remarks' section:
  • Disabling effects: Including details of the physical or mental effects of the relevant medical conditions listed under diagnosis/other diagnosis
  • Additional information: Including details about the effects of any treatment and the likely prognosis, including confirmed dates for surgery, chemotherapy etc
• The completed form should indicate if the patient is unable to travel to a DWP/Jobcentre Plus examination centre as a result of their medical condition. Otherwise it will be assumed that the patient is able to travel to an examination centre up to 90 minutes' travelling time from their own home or normal place of residence.

• If it is not possible to enter a diagnosis on forms Med 3, Med 4 or Med 5 as precisely as the rules require, the local DWP office should be notified at the same time as the statement is issued, by sending a completed form Med 6.
• A copy of the Med 6 certificate can be found included in each pad of Med 3 and Med 4 forms.
• The address of the nearest DWP office can be found in the telephone directory under ‘Department for Work and Pensions’.
• On receipt of form Med 6, if the patient is claiming a state incapacity benefit, a DWP Medical Officer will write to the patient's GP requesting a brief report. This report provides an opportunity to provide a full diagnosis to the Medical Officer.

• A GP may suggest an independent assessment of a patient by the DWP earlier than would be required under normal control procedures, e.g. if there are any doubts about the patient's ongoing incapacity for work.
• A form RM 7 should then be sent to the local DWP office, which will take appropriate action.
• A copy of form RM 7 is included in each pad of Med 3 and Med 4 statements.
• The current form RM 7 does not ask for any clinical information.

• A form DS 1500 should be issued if requested by a patient (or their representative) if the patient may be suffering from a potentially terminal illness. The relevant definition of terminal illness is a progressive disease where death as a consequence of that disease can reasonably be expected within 6 months.
• The DS 1500 should be handed to the patient (or their representative) and not sent directly to the DWP.
• A fee is payable by the DWP for the completion of the form.
• DS 1500 forms are supplied in booklets by the Department on written application (DWP, DCS Unit 12, Manchester Road, Heywood, OL12 2PZ).
• The DS 1500 asks for factual information and does not require a prognosis. The report should contain details of:
  • The diagnosis
  • Whether the patient is aware of their condition and, if unaware, the name and address of the patient’s representative requesting the DS1500
  • Relevant current and proposed treatment
  • Brief clinical findings

• In October 2008, Employment and Support Allowance (ESA) replaced the existing system of incapacity benefits for new applicants.
• ESA provides financial support to disabled people or individuals with a health condition that affects their ability to work.
• GPs will still be asked to provide ‘statements of incapacity for work’ (usually on form Med 3) until the independent Work Capability Assessment is carried out.
• GPs may also be asked to complete a form ESA113 for patients with a severe disability, who might be entitled to benefit without the need for a face-to-face assessment.