BACKGROUND A practice manager contacts our advice line in regard to a patient with lower back pain who had previously been issued a Med 3 (fit note). The fit note will soon expire and Mr B – who has a desk job – is still in obvious pain and has asked for more time off. In discussing his condition with a GP, the patient confided that he does some volunteer work and is undertaking a part-time course at college. The GP expressed his reluctance to “tick the box” advising that Mr B is not fit for work, given the patient’s other activities. He asked about other possible options, such as a phased return to work or amended duties. Mr B has now phoned the practice manager again demanding the GP sign him off for another six weeks. The practice manager asks for advice on how to respond.

ANALYSIS/OUTCOME An MDDUS adviser responds pointing out that the Department of Work and Pensions

provides specific guidance on issuing fit notes. This states that GPs should provide simple fitness for work advice (not job specific) to a patient to help them return to work and it is then up to that patient and their employer to discuss this advice and consider possible solutions. The Med 3 form offers the option to tick:

“May be fit for work taking account of the following advice”, along with an open field to provide advice on the functional effects of a patient’s condition. This offers flexibility to the patient and their employer to discuss ways to accommodate the condition, which might include changing duties or reduced hours. The adviser also directs the practice manager to GMC guidance which states that doctors must be “honest and trustworthy when writing reports, and completing or signing forms, reports and other documents” and must ensure that any such documents are not “false or misleading”. It also states that doctors

should use their own judgement when applying these principles in their everyday practice, and that they must be able to explain and justify any decision made or action taken. The practice manager is advised that all

such guidance would be relevant in explaining to Mr B the basis for any decision on fitness to work. In addition the GP should be available to discuss the basis of the decision, and it should be made clear that, if the patient remains dissatisfied, he is entitled to seek a second opinion.

KEY POINTS ●Consult relevant guidance in discussing and issuing fit notes. ●Ensure you are able to justify any decision made or action taken in addressing a patient’s fitness to work and that this is recorded in the notes.


BACKGROUND A dentist emails the MDDUS advice line having read a comment on an online dental forum saying that a “mixed” practice should not offer private patients root canal treatment if also offered to NHS patients at an appropriate (lower) charge. She asks for clarification on this from a dento-legal standpoint.

ANALYSIS/OUTCOME A dental adviser responds that the important issue here is not whether the practice is mixed NHS/private but whether an individual patient is registered as an NHS or a private patient. An NHS patient will be entitled to the full range of available treatment on the NHS and that would include root canal treatment (RCT) at the appropriate charge. A private patient or one on a practice plan should expect to pay for treatment, including RCT, at an agreed private fee or via their monthly plan payments. What is most important in a mixed practice is to make it clear to each

individual patient whether they are being seen on the NHS or privately. All patients must be given a treatment plan and written cost estimate which should indicate the basis on which treatment is being provided. There may be occasions where NHS patients opt for private treatment and this is entirely acceptable as long as the patient has not been coerced or misled to believe that the treatment is not available on the NHS – or would be provided more successfully on a private basis (“upselling”).

KEY POINTS ●NHS patients have a right to consider private treatments but should be offered all available and clinically justifiable NHS options in a neutral and professional manner. ●Such discussions must be properly reflected in the records and relevant paperwork completed.


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