Certificates, Rules and Regulations in General Practice

What we’ll cover

• Death certification and the coroner

• Fitnotes (med3) and sickness absence

• Travel rules (flying and driving)

• Controlled drug prescribing

Death certification

• Write one if you have attended the deceased within the last 14 days (now 28 days since Covid), and are able to give a cause of death

• Format:

• 1a) Disease that directly lead to death

• 1b) What led to 1a (didn’t directly cause death)

• 1c) What led to 1b (didn’t directly cause death)

• 2) Conditions that contributed, but didn’t directly lead to death in 1a/b/c

Examples

• 1a) Ischaemic Stroke

• 1b) Atrial Fibrillation

• 1a) Metastatic Lung Cancer

• 1a) Bronchopneumonia

• 1b) Immobility

• 1c) Parkinson’s Disease and Rheumatoid Arthritis

• 2) Diabetes Mellitus

• You can have joint cause of death e.g. 1a) Lower Respiratory Tract Infection and Urinary Tract Infection

• You can just have 1a alone

• You can go beyond 1c if needed (1d, 1e….)

• Old age (Frailty of old age) is acceptable, but only if above a certain age [NB this varies between coroners jurisdictions], and if other causes cannot reasonably be given

• There is a separate death certificate book for still births: If born after 24 weeks gestation but did not show any signs of life or did not breathe should be certified using the Certificate of Stillbirth.

• Up to 23+6/40= NO CERTIFICATE unless they ever showed signs of life (in which case neonatal death certificate)

• Separate certificate for neonatal deaths. Any death of a live-born infant occurring within the first twenty-eight days of life should be certified using the Neonatal Death Certificate

Death certificates- Do nots

• Do not write a mode of death without qualifying it e.g. 1a) Renal failure, 1a) Cardiac arrest, 1a) Multiorgan failure, 1a) Shock etc. are not acceptable.

• “Natural causes”, “cardiovascular event” etc. are not acceptable either.

• Something in 1b however can qualify this… e.g. 1a) Multiorgan failure 1b) Pancreatitis

• 1a. Liver failure 1b. Hepatocellular carcinoma 1c. Chronic Hepatitis B infection

2. Congestive cardiac failure and hypertension

• Do not list every single comorbidity in 2 if it is not relevant

• Do not use abbreviations.

• Do not write the certificate if the death needs to be notified to the coroner

What deaths need referring to the coroner?

• The cause of death is unknown

• All deaths of children and young people under 18, even if due to natural causes.

• Not seen by the certifying doctor either after death or within 14 days (28 since covid) before death

• Death was violent or unnatural or was suspicious

• Death may be due to an accident (whenever it occurred)

• Death may be due to self-neglect or neglect by others

• Death may be due to an industrial disease or related to the deceased’s employment

• Death may be due to an abortion

• Death occurred during an operation or before recovery from the effects of anaesthetic

• Death may be suicide

• Death occurred during or shortly after detention in police or prison custody.

What can the coroner do?

• Can authorise you to issue MCCD with no further action

• Can hold a documentary inquest

• Can hold a formal inquest

• Can hold an inquest with a jury

• Can issue a “Regulation 28” (Report to prevent further deaths)

• Can order a post mortem (NB family cannot object to this, nor deceased indicate refusal before death e.g. advanced directive to refuse an autopsy)

Question

• A frail, elderly patient dies from a pulmonary embolism following a blood clot in the leg.

• They had fallen over and sustained a fractured neck of femur only 5 days earlier before it was operated on.

• PMHx: Dementia, Parkinsons Disease, Glaucoma, Hypertension, Hypothyrodism, Psoriasis

• Can you write the MCCD?

• Why does this need referring?

• Exercise: In referring to the coroner, they ask you to propose a cause of death

Exercise: Proposed cause of death

• A frail, elderly patient dies from a pulmonary embolism following a blood clot in the leg.

• They had fallen over and sustained a fractured neck of femur only 5 days earlier before it was operated on.

• PMHx: Dementia, Parkinsons Disease, Glaucoma, Hypertension, Hypothyrodism, Psoriasis

• 1a) Disease that directly lead to death

• 1b) What led to 1a (didn’t directly cause death

• 1c) What led to 1b (didn’t directly cause death

• 2) Conditions that contributed, but didn’t directly lead to death in 1a/b/c

• 1a) Pulmonary Embolism

• 1b) Deep Vein thrombosis

• 1c) Immobility caused by left sided fractured neck of femur

• 2) Parkinsons Disease, Dementia

What about: Glaucoma, Hypertension, Hypothyrodism, Psoriasis?

NB: There may be a number of acceptable slight variations of this proposed cause. The important thing is the cause is logical, and on the balance of probabilities best explains the cause of death.

Possible PDP idea

• End of Life care is an important component of general practice

• You may consider a PDP that includes your reflection on looking after a patient at the end of life, prescribing pre-emptives, writing a death certificate/referral to the coroner and doing as part of a CBD.

• You may also wish to observe a post mortem (occur at LCH) or attend a coroners court hearing

Further reading

• https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/757010/guidance-for-doctors-completing-medical-certificates-of-cause-of-death.pdf

• Medical Examiner system

• https://www.england.nhs.uk/establishing-medical-examiner-system-nhs/

Any questions on death certificates/coroner?

Fitness to work

Work, School and Nursery exclusion

Duration Conditions

No exclusion ConjunctivitisInfectious mononucleosisHeadlice, ThreadwormsRoseola5th disease

24 hours Scarlet fever (after starting Abx)

2 days Whooping cough (after starting Abx, or 21 days from onset of symptoms if no Abx)Diarrhoea and vomiting (when settled for 48hrs)

4 days Measles

5 days Mumps

Until recovered Influenza

Until treated Scabies

Until crusted over Impetigo, chickenpox

Sick leave and holiday

• Statutory holiday entitlement is built up (accrued) while an employee is off work sick (no matter how long they’re off).

• Any statutory holiday entitlement that is not used because of illness can be carried over into the next leave year. If an employee is ill just before or during their holiday, they can take it as sick leave instead.

• An employee can ask to take their paid holiday for the time they’re off work sick.

• Employers cannot force employees to take annual leave when they’re eligible for sick leave.

Fitnotes

• Issued free of charge to patients whom they provide clinical care

• Historically called ‘Sick notes’ but emphasis moved to ‘fitness’ rather than ‘sickness’

Fitnotes (Med-3)

• You do not need to issue a fit note for the first 7 calendar days of a patient’s sickness absence. Patients can self-certify for this period (SC2 to claim statutory sick pay)

• If you assess that your patient’s health affects their fitness for work, you should give them a fit note indicating whether your patient is not fit for work OR may be fit for work.

• GPs should note that they can back date a fit note; in certain situations, parts of the fit note may need to include dates which are earlier than the date of the statement.

• You do not need another note to indicate you are fit to return to work.

• If a patient feels well enough to return before the expiration date, they can return to work early without needing a new fitnote

Options

• You are not fit for work

• You may be fit for work… may benefit from:• Phased return• Altered hours• Amended duties• Workplace adaptations

• If you tick ‘may be fit’ but the employer cannot make adjustments, then the fitnote reverts to ‘not fit for work’. It does not need to be rewritten.

What to include

• Advice given to the patient, along with other factual information including an accurate diagnosis, except on the occasions when a doctor feels that it could be prejudicial to their patient’s wellbeing if the true diagnosis were given.

• The comments section on medical statements allows for additional comments about the disabling effects of the diagnosed condition, its treatment and prognosis.

• Fit notes should indicate clearly the information required. Generally GPs should not speculate but should provide only factual information and should not certify something they are unable to verify.

• GPs are reminded that they might be asked to provide further information to substantiate certification in such circumstances. In cases where you consider that a patient would benefit from the help or advice of a Disability Employment Adviser (DEA) this opinion should also be included in the remarks section.

Fit note facts/questions

• Q: Can a nurse practitioner sign a Med3?

• No: “Only a registered medical practitioner can issue statements of a person’s incapacity for work”

• Q: Can I backdate a Med3?

• Yes: “can only be issued for a backdated period when it is based on a previous assessment.” can be F2F, telephone or based on a report from another Dr/HCP. Can issue on or after this date, but not before.

• Q: My patient has 2 part time jobs- do they need 2 Med3s?

• No: “You can only issue a duplicate Med 3 if the original statement has been lost. You should clearly mark it “Duplicate”. Advise people with more than one employer to submit the statement to their main employer, who can note the details of the advice you have given. They can then present the statement to their second employer.”

Further reading

• https://www.gov.uk/government/publications/fit-note-guidance-for-gps

PDP idea

• You will have patients who you support in a sickness absence period, you may wish to reflect on a patient who you have completed a Med-3 for, and discuss a patient’s sickness absence as part of a CBD, you may also think about diseases that may be caused or affected by work.

• Faculty of Occupational Medicine

• https://www.fom.ac.uk/

• Society for Occupational Medicine

• https://www.som.org.uk/

Travel rules

Driving

• Group 1 driver- Car/Motorbike. Valid until age 70, then renew every 3 years (no upper age). If in receipt of mobility component of PIP can hold license from 16

• Group 2 driver- HGV, Train, Bus, Taxi …. Where responsible for other passengers and/or heavy vehicle. (Usually) age 21+ and valid until age 45. Then renewed at 45 and 5 yearly until age 65, then annual renewal with no upper age limit.

• Vision requirements

• Group 1: 6/12 (can be corrected)

• Group 2: 6/7.5 (glasses corrective power not more than (+) 8 dioptres, contact lenses no limit)

How long can’t I drive for? (Group 1)

• TIA/Stroke= 1 month …. No need to notify DVLA unless deficit affects ability to drive

• Acute Coronary Syndrome= 1 week if treated with PCI successfully, if not treated with PCI/unsuccessful then 28 days. No need to notify DVLA

• CABG= 1 month. No need to notify

• Vasovagal episode with clear provocation= no restriction and no need to notify

• Pacemaker insertion/change= 1 week and MUST notify DVLA

• First fit= 6 months and MUST notify DVLA

Further reading

• https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/834504/assessing-fitness-to-drive-a-guide-for-medical-professionals.pdf

• Lots of advice including Group 2

• If in doubt, look it up.

Flying

• A simple fitness-to-fly test is the ability of a patient to walk 50 metres unaided at a normal pace, or to ascend one flight of stairs, without becoming severely dyspnoeic

• Most airlines prohibit travel after 36/40 singleton and 32/40 for multiple pregnancies. Most airlines require confirmation of dates for pregnancies >28/40 (including EDD and confirm pregnancy progressing well)

• Insulin-dependent diabetes: normally required a letter of authorisation from their doctor to allow carriage of needles in their hand luggage. Insulin should be carried in a cool bag or pre-cooled vacuum flask. Insulin should not be stored in the hold.

Contraindications to flying• Severe respiratory disease where the patient is breathless at rest

• Unstable angina, uncontrolled arrhythmia, poorly controlled heart failure

• Following an MI: Uncomplicated (7/7) or complicated (4-6/52)

• DVT- until adequately anticoagulated and absence of pulmonary complications

• Suspected pneumothorax, pneumomediastinum

• Untreated communicable disease

• Acute gastrointestinal bleeding

• Severe anaemia - Hb less than 7.5 g/dL, recent sickling crisis

• “Psychiatric disturbance”

• Infants “should be at least 2 days old before undertaking air travel. Preferably they should be 7 days old”

• 10 days after surgery to a hollow viscus

• Uncomplicated chest surgery 3-4/52

• Eye surgery involving intraocular injection of gas- until ophthalmologist has confirmed complete gas resorption

Flying advice- Civil Aviation Authority

• https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Guidance-for-health-professionals/Assessing-fitness-to-fly/

• https://www.fitfortravel.nhs.uk/destinations

Controlled Drugs

What does this mean?

• Single use only

• Newly licensed medicine

• Prescription Only Medicine

Controlled drugs

• Schedule 1- no medicinal use (e.g. LSD). Need a home office license

• Schedule 2- need to be locked away and registered, and written in words and figures e.g. diamorphine

• Schedule 3- do not need to be locked away or registered, but need to be written in words and figures e.g. Tramadol, buprenorphine, temazepam

• Schedule 4: divided into two, no locked storage or register: part 1 minimal control e.g. diazepam. Part 2 e.g. anabolic steroids. No special prescribing requirement

• Schedule 5: preparations of CDs but in weak strength e.g. codeine, oramorph. No locked storage or register or special prescribing requirement

• Invoices should be kept for 2 years

Controlled drug prescription

• Schedule 2 and 3

• Include the date, prescribers practice address (Must be in UK!)

• The name and address of the patient (use of a PO Box is not acceptable);

• The form (e.g. tablets, liquid) must be stated

• Dosage and strength

• Frequency clearly stated (As directed is NOT acceptable)

• Total quantity to be supplied in words and figures- ampules, tablets, millilitres e.g. “Supply 10 (ten) ampules”, “supply 56 (fifty six) tablets”

Exercise

• You are prescribing a patient Morphine Sulphate MR tablets at 20mg twice daily and need 28 days supply

• Unfortunately the printer has broken…..

• Write this out as a controlled drug prescription

• Morphine Sulphate MR 20mg tablets

• 20mg twice daily

• Supply 56 (fifty six) tablets

• Signed: A Doctor

• GMC: 123 ABC

Summary

• Death certification and the coroner

• Fitnotes (med3) and sickness absence

• Travel rules (flying and driving)

• Controlled drug prescribing

Thank you for listening… Any questions?