Certifying fitness for patients with cardiovascular disease
MRC Research Fellow and General Practitioner University of Southampton, UK
E-mail: caes{at}soton.ac.uk
GPs have a responsibility for the community in which they work, which extends beyond the consultation with an individual patient. This is laid out in the GP curriculum in the community orientation domain (domain 5) of the core statement ‘Being a General Practitioner’. This includes balancing the best interests of one patient (for instance, an individual's need to drive in order to work) against the interests of the wider community (in this case, a GP's responsibility to maintain public safety). The daily work of family doctors is determined by the makeup of the community and therefore they must understand the community in which they work and its character in terms of socio-economic and health features (for example, high or low numbers of people signed off work). The GP is in a unique position to consider how these issues interrelate with health, and the importance of each within their community to help inform wider local and national community policies. A GP must also develop an understanding of how the healthcare system can be used by people for reasons other than simply obtaining healthcare – such as getting a sick note or asking the GP to complete a ‘fit to exercise’ form so they can joint a local gym or sportsclub. It is important to have a working knowledge of criteria on which to base your decisions. This article outlines the relevant legislation and procedures involved in certifying fitness in primary care.
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Fitness to work |
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The RCGP Curriculum statement 15.1 (Cardiovascular problems) requires GPs in training to recognize the impact cardiovascular problems have on disability and fitness to work as part of a holistic approach towards the patient. In the UK, the ‘Own occupation’ test applies to the first 28 weeks of any illness for those claiming statutory sick pay from their employer, or those claiming incapacity benefit who have done a substantial amount of work in the 21 weeks prior to the illness. As a GP, you must make a decision about whether the patient is fit to do his or her own job. For example, it is reasonable to expect someone working behind a desk to go back to work after a pacemaker insertion within a week, but a heavy labourer may need more time. The Department of Work and Pensions (DWP) has issued guidelines for time that patients should be expected to take off following common cardiovascular procedures (Table 1).
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The forms that are used to certify short-term sickness are:
- SC1 - Self-certification form for people not eligible to claim statutory sick pay who wish to claim incapacity benefit. This form can be used to certify the first seven days of illness. Forms are available from Jobcentre Plus offices and GP surgeries
- SC2 - Self-certification form for people able to claim statutory sick pay. Like form SC1, this form can be used to certify the first seven days of illness. Forms are available from employers, Jobcentre Plus offices and GP surgeries
- Med 3 - Filled in by a GP or hospital doctor who knows the patient, for periods of incapacity to work likely to be longer than seven days. If return within 14 days is forecast, give a fixed date of return (‘closed certificate’). If longer, specify a period of time (e.g. ‘2 months’) (‘open certificate’). Before the patient returns to work reassess the patient and give a further certificate with a fixed date of return. Only one Med 3 can be issued per patient per period of sickness. If a Med 3 is mislaid, reissue it and mark the new certificate ‘duplicate’
- Med 5 - Can be filled in by a GP or hospital doctor if the doctor has not sent the patient but, on the basis of a recent written report from another doctor (received within a month of the date of signing the Med 5), is satisfied that the patient should not work. In this case, the certificate should not cover a forward period of more than a month. The Med 5 form can also be used if a patient asks for a certificate and it is more than a day since the doctor issuing the certificate has seen the patient, but it is clear that the disability is ongoing. Finally a Med 5 can be used if a patient returned to work without receiving a closed certificate
A Med 6 can be used when it is felt that putting a diagnosis on a Med 3, 4 or 5 would be harmful either directly to a patient or through the employer knowing the diagnosis. A vague diagnosis is put on the Med 3, 4 or 5 form and a Med 6 completed which requests the DWP to send a form to obtain more precise details. The dual role of the GP as advocate of the patient and agent of the state in certifying fitness to work can be problematic (Box 1).
| Box 1 Case study: A man aged 42 years is unemployed and had a myocardial infarct 2 months ago. He seems to have made a good recovery, has no ongoing symptoms and his recent exercise ECG did not reveal any cause for concern. He comes to ask for another extension of his sick note as he still feels unable to work. You examine him and there is nothing abnormal to find. He seems fit to work to you. What can you do? Certifying sickness is a difficult ethical area for GPs. On the one hand you are working for your patient to provide a service by certificating illness - on the other, you have a responsibility to act for the state and taxpayer not to authorize unjustified payment of sickness benefits. There is no right or wrong way to deal with this situation. Initially try to explore the reasons why the person wants to remain ‘sick’. Sometimes there are financial incentives - for example sick pay may be higher than usual benefits; sometimes the illness absolves the patient from other unwanted responsibilities (for example, court appearances); it might be more convenient to be ‘off sick’ - for example to provide child care during school holidays; or on other occasions there may be another legitimate reason why the patient cannot work that has not been explored (for example, depression or lack of confidence following a myocardial infarction). If a reason is forthcoming, and does not reveal any further medical reason for sickness certification, explain that sick notes cannot be used to deal with social problems and that you have a duty not to issue sick notes for those reasons. Explore ways to get around the problem - such as a review of family benefits, or referral to the health visitor for information about child care provision. If there is no reason forthcoming, or the patient still demands a sick note, then as a GP in training you should involve your trainer or clinical supervisor. There is a choice of possible courses of action. You can refuse to sign the patient ‘off sick’. However, that may prompt a confrontation with the patient or affect your future relationship with that patient. Alternatively you can issue a sick note and send form RM7 to the DWP (this is only an option if the patient is claiming state incapacity benefit). This requests that a medical assessment is carried out earlier than would otherwise occur. Finally you could acquiesce and issue another ‘sick note’. Your relationship with the patient will remain good, but it may encourage the patient to come back for more sick notes with no justification and/or assume a long-term sick role.
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The Personal Capability Assessment
This assessment was formerly called the ‘All work’ test. The personal capability assessment checks the patient for ability to work on a variety of different mental and physical health dimensions. It is not diagnosis dependant and applies to everyone after 28 weeks’ incapacity. It also applies to those who do not qualify for the ‘own occupation test’ from the start of their incapacity.
Claimants are sent form IB50 to complete themselves and are asked to obtain form Med 4 from their GP. If the DWP is not happy to continue paying their benefit on the basis of these reports, the applicant is called for a medical examination. Cardiovascular conditions that exempt patients from further examination include:
- Receipt of highest rate care component of disability living allowance (DLA), constant attendance allowance or >80% disabled for other benefit purposes
- Hemiplegia - for example as a result of stroke
- Severe progressive cardio-respiratory disease that persistently limits exercise tolerance
Private certificates
Some employers request private certificates in the first week of sickness absence. These requests should be made in writing by the employer. If you, as a GP, choose to provide the service, you may charge both for a private consultation and the provision of a private certificate. The company should accept full responsibility for all fees incurred by the patient.
Helping patients to get back to work
Getting back to work after a long period of incapacity, for example following a myocardial infarct or stroke can be difficult. The illness may have knocked the patient's confidence and lasting effects of the illness may make the work harder than it was before. Liaise with the patient's employer. Often it is possible for patients who have had a major illness to ease back into work by working at reduced hours for a period of time before going back to their full duties.
The Disability Discrimination Act (1995) requires employers in some circumstances to make reasonable adjustments for an employee with a long term disability. Advise patients to seek specialist advice from their work place Human Resources Department or Occupational Health Department, or the Citizen's Advice Bureau.
For patients not in regular work who wish to go into work but have a disability as a result of a cardiovascular illness, disability employment advisers are provided by the Employment Service. These can be accessed directly by the patient through enquiry at the local Jobcentre Plus office, by writing a comment to the effect that intervention would be helpful in the comments box on form Med 3, or by writing to the local Jobcentre (with the patient's permission).
Incapacity benefits do allow very limited work, for example therapeutic work (though this must be done as part of a treatment programme and in an institution that provides sheltered work for people with disabilities) or voluntary work. It is also allowable to work as a local authority councillor or disability expert on an appeal tribunal or member of the DLA advisory board (though not for more than one day a week).
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Fitness to make decisions |
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Curriculum statement 9 (Care of older adults), in the Primary Care Management domain, requires GPs in training to act as advocates for their patients, and in particular to understand the legal issues that may arise as a result of inability to make decisions.
The Mental Capacity Act of 2005, came into force in two parts in April and October 2007 in England and Wales. Similar legislation is in operation elsewhere in the UK. Mental capacity means the ability to make decisions or take actions affecting daily life – for example when to get up, what to wear, what to eat, or whether to go to the doctor when feeling ill. It can also mean the ability to take more major decisions such as where to live or how to manage large sums of money. Some people with cardiovascular disease, for example patients who have suffered a stroke, may have difficulty making these decisions. The Mental Capacity Act makes it clear who can take decisions in which situations, and how they should go about it. It also allows people to plan ahead for a time when they may lack capacity.
The Act contains five key principles:
- Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise
- Every adult must be given all possible help and support to make their own decisions, and to communicate those decisions where necessary, before they can be assumed to have lost capacity
- Just because someone makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision
- Anything done or any decision made on behalf of someone who lacks capacity must be done in their best interests
- Anything done or any decision made on behalf of someone who lacks capacity should be the least restrictive of their basic rights and freedoms
Assessing capacity
The Mental Capacity Act sets out a clear test for assessing whether someone lacks capacity to make a particular decision at a particular time. As a GP in training, you may be asked to give an opinion on a patient's mental capacity to make decisions. If you are asked to do this, discuss the matter with your trainer or clinical supervisor. You should have access to the patient's records and ideally know the patient. In addition:
- Seek information from friends, relatives, carers and/or the patient's independent mental capacity advocate, if one has been appointed
- Examine the patient, assess the type and degree of deficit
- Decide if there is an impairment of, or disturbance in, the functioning of the patient's brain or mind
- If there is a disturbance, decide if the patient is able to make the particular decision in question – in particular: Can the patient understand the information relevant to that decision, including the likely consequences of making, or not making, that decision? Can the patient retain that information? Can the patient use or weight that information as part of the process of making the decision? Can the patient communicate that decision by any means?
- Decide if assessment should be postponed while measures are taken to improve capacity
- Record all the above information
Even if you think a proposed action is in the patient's best interests, you must not judge the patient capable if that is not clearly the case. If in doubt, seek a second opinion.
Best interests
The Mental Capacity Act enables patients’ advocates (usually friends, relatives or carers) or suitable professionals, such as doctors or social workers, to act in patients’ best interests on their behalf. It is important in such situations to take all factors affecting the decision into consideration, involve the patient with the decision-making as far as possible, take the patient's previous known wishes into consideration, and consult everyone else involved with the patient's care/welfare. In situations in which there is disagreement about the patient's best interests, the decision can be referred to the Court of Protection. This applies provision of medical care. As long as the Mental Capacity Act has been adhered to, and you can show that you have assessed the patient's mental capacity and acted in the patient's best interest, you can do investigations and treat patients who lack mental capacity to consent.
Assignment of decisions to others
In some cases, for example patients with vascular dementia, the ability to make decisions is lost. Responsibility for running the patient's affairs must then be handed over to someone else.
Lasting Power of Attorney (LPA) has replaced the old system of Ordinary and Enduring Power of Attorney from October 1st 2007 in England and Wales. However, patients with existing Enduring Powers of Attorney will still be able to use them. Like Enduring Powers of Attorney, LPAs are made whilst a person is still competent to make decisions and intended to come into force should they become incapable of making their own decisions. To be valid, LPAs must be registered with the Court of Protection. The attorney can make decisions on behalf of the person who has made the LPA (the donor) and must act in the donor's best interests. There are two types of LPA – a property and affairs LPA and a personal welfare LPA.
An LPA for property and affairs allows someone else to manage a person's financial affairs. Unless specified otherwise, an LPA for property and affairs can be used whilst the donor still has capacity. An LPA for personal welfare relates to all matters concerning a person's care and treatment. The attorney cannot consent to or refuse treatment for the donor whilst the donor retains the capacity to do so for him- or herself. The attorney only has the authority to make decisions about life-sustaining treatment if the LPA specifies that.
If a person becomes incapable of managing his or her affairs but has not previously signed an LPA, it may be necessary for someone, usually the nearest relative, to apply to the Court of Protection for the appointment of a ‘deputy’ to do so. Alternatively, if the patient's affairs are simple (e.g. state pension) direct arrangements can be made with relevant authorities.
Advance decisions
For many patients with intractable cardiovascular disease, such as heart failure, it is sensible to make an advance decision - otherwise known as an advance directive or living will. These are statements in which a person makes a decision about medical treatment in case he or she becomes incapable of making that decision later. The Mental Capacity Act puts advanced decisions on a statutory footing. Respect any refusal of treatment given when the patient was competent, provided the decision is clearly applicable to present circumstances, there is no reason to believe that the patient has altered that decision and the decision was made without undue pressure from others.
Advance decisions do not have to be written, but it is easier if they are. Advance decisions to refuse life-sustaining treatment must be specific to a particular treatment (such as refusal to have cardio-pulmonary resuscitation), written and signed by the person making the decision, or a representative if the person is unable to sign, and a witness. They cannot include decisions about treatment the person would like, only treatment the person would wish to refuse, and cannot include directions to end the person's life prematurely. Doctors may object to carrying through the wishes of a patient in an advance directive. In such cases they should refer the patient to a doctor who is willing to carry out the patient's wishes.
Testamentary capacity
Testamentary capacity is the capacity to make a will. Anyone can make a will provided they understand the nature and effect of making a will, extent of property being disposed of and claims others may have on that property, as long as the decisions are not the result of any underlying medical condition (e.g. due to a delusion). Decisions do not have to seem rational to others, especially if they are consistent with the patient's pre-morbid personality.
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Fitness to drive |
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TOPThe GP curriculum and...Fitness to workFitness to make decisionsFitness to driveFitness to flyFitness to perform sporting...References |
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| Driving licence holders (or applicants) have a legal duty to inform the Driver and Vehicle Licencing Agency (DVLA) of any disability likely to cause danger to the public if they were to drive.
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Driving licence types
There are two main categories of driving licence in the UK. Group 1 licences are ordinary licences for driving a car or motorcycle. Old-style licences expire on the holder's seventieth birthday and then must be renewed three yearly. New photocard licences are automatically renewed 10 yearly until the age of 70. Applicants are asked to confirm that they have no medical disability. If they do this, then no medical examination is necessary.
Group 2 licences enable holders to drive lorries and buses. They can be held from 21 years of age and are initially valid until the holder's forty-fifth birthday. From age 45 to the holder's sixty-fifth birthday the licence is renewable every five years, and over the age of 65 years, the licence is renewable annually. Medical examination is needed to renew Group 2 licenses. Applicants must bring form D4 (available from post offices) with them. Examinations take around half an hour and a fee may be charged by the GP.
Determining fitness to drive
The GP curriculum specifies that GPs should be able to advise patients appropriately regarding driving according to their cardiovascular risk and the DVLA guidelines.
Always advise patients with any disorder that might cause danger to others if they drove, not to drive and to contact the DVLA (Box 2). The DVLA gives advice on when the patient can start driving again. Specific guidance on criteria for fitness to drive for patients with cardiovascular conditions is contained in Table 2. Unless otherwise stated, Group 1 drivers do not need to inform the DVLA about their condition. Group 2 drivers always need to inform the DVLA about their condition.
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| Box 2. What should I do if a patient continues to drive despite advice to stop? If the patient does not understand the advice to stop driving: inform the DVLA. If the patient does understand the advice to stop driving:
Always consider discussing the case with your trainer or clinical supervisor and/or contacting your medical defence body for advice.
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| Box 3. Resumption of physical activities following myocardial infarct Physical activity: Advise gradual increase in activity. Ensure goals given match those given by local cardiac rehabilitation. As a guide:
Sexual activity:
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Fitness to fly |
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Passengers are required to tell the airline at the time of booking about any conditions that might compromise their fitness to fly. The airline's medical officer must then decide whether to carry them or not. For patients with cardiovascular disease, the main hazards of flying are due to:
- Cabin pressure – oxygen levels are lower than at ground level and gas in body cavities expands 30% in flight
- Inactivity and dehydration
- Disruption of routine
- Alcohol consumption, and
- Stress and excitement
There are some specific contraindications to flying for patients with cardiovascular disease. Patients with heart disease should not travel if they have unstable angina, poorly controlled heart failure or an uncontrolled arrhythmia. Patients should also not fly less than 10 days after an uncomplicated myocardial infarct (many airlines state two weeks) and then only if able to climb a flight of stairs without difficulty. Following chest surgery, or abdominal surgery (for example for aneurysm repair), patients should not fly for at least 10 days. Following angiography or angioplasty, patients should not fly for three to five days. For patients who have suffered a stroke or transient ischaemic attack, travel should be delayed (depending on clinical state) for at least three days following the attack. Finally, due to the increased risk of thrombo-embolism due to flying, patients who have suffered a deep vein thrombosis should not travel until they are established on anticoagulants.
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Fitness to perform sporting activities |
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TOPThe GP curriculum and...Fitness to workFitness to make decisionsFitness to driveFitness to flyFitness to perform sporting...References |
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GPs are commonly asked to certify fitness to perform sports. Normally the patient will come with a medical form. If there is a form, request to see it before the medical. If there is no form and you are unsure what to check, telephone the sport's governing body or the event organizer. A fee is payable by the patient.
Many gyms and sports clubs also ask older patients and patients with pre-existing conditions or disabilities to check with their GP before they will sign them on. Assuming that a suitable regime is undertaken most people can participate in some form of sporting activity. Consider the patient's baseline fitness, check blood pressure and medications and recommend a gradual introduction to any new forms of exercise.
Remember – signing a form may result in legal action against you should the patient NOT be fit to undertake an activity. Where possible include a caveat, for example: "based on information available in the medical notes the patient appears to be fit to ...., although it is impossible to guarantee this." If you are unsure, consult your local LMC or medical defence organization for advice.
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References |
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RCGP Curriculum statements. Accessed via website: www.rcgp.org.uk.
— Number 9. Care of older adults http://www.rcgp-curriculum.org.uk/PDF/curr_9_Care_of_older_adults.pdf [date last accessed 5.12.07].
— Number 15.1. Cardiovascular problems http://www.rcgp-curriculum.org.uk/extras/curriculum/statementDetails.aspx?id=23.
Dunn N, Everitt H, Simon C. Cardiovascular problems in general practice (2007) OUP ISBN: 97801992335384.
Citizens Advice Bureau. Benefits for people who are sick or disabled. Accessed viahttp://www.adviceguide.org.uk/index/life/benefits/benefits_for_people_who_are_sick_or_disabled.htm [date last accessed 5.12.07].
Department of Work and Pensions (DWP) website: www.dwp.gov.uk.
DWP. Medical Evidence for Statutory Sick Pay, Statutory Maternity Pay and Social Security Incapacity Benefit purposes: A guide for registered Medical Practitioners. IB204. Accessed via http://www.dwp.gov.uk/medical/medicalib204/ib204-june04/ib204.pdf [date last accessed 5.12.07].
Disability Discrimination Act Accessed via: www.direct.gov.uk.
Jobcentre Plus Sick and Unable to Work. Accessed via http://www.jobcentreplus.gov.uk/JCP/Customers/WorkingAgeBenefits/Dev_007969.xml.html.
HM Government. The Mental Capacity Act (2005) http://www.dca.gov.uk/legal-policy/mental-capacity/mibooklets/booklet03.pdf [date last accessed 5.12.07].
Making Decisions: a guide for people who work in health and social care (2007) Available from: www.guardianship.gov.uk.
DVLA At a glance guide to the current medical standards of fitness to drive for medical practitioners. Available from: http://www.dvla.gov.uk/media/pdf/medical/aagv1.pdf [date last accessed 5.12.07].
Medical advisers from the DVLA can advise on difficult issues - contact: Drivers Medical Unit, DVLA, Swansea SA99 1TU or Tel: 01792 761119.
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