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CHAPTER4 Social aspects of primary care
Certifying fitness towork
Individuals must self- certify for the rst 7d of incapacity, then sickness certication from a GP is needed until the Work Capability Assessment (WCA)
is carried out.
Own occupation test Applies to those claiming Statutory Sick Pay
(SSP) for the rst 28wk of illness. The GP assesses if the patient is t to do
his/ her own job.
Work Capability Assessment Carried out by employment advisers
contracted to the Department for Work and Pensions (DWP). It is not
diagnosis dependent and assesses a variety of dierent mental/ physical
health dimensions for ability to work. WCA is performed within the rst
13wk of any claim for Employment Support Allowance (ESA) or Universal
Credit and applies to:
• Everyone after 28wk incapacity
• Those who do not qualify for the ‘own occupation test’ from the start
of their incapacity (i.e. do not qualify for SSP)
Initial information All applicants are asked to ll in the ‘Limited capability for
work’ questionnaire which explores how the individual’s medical problem
impacts ability to work. Sometimes medical reports from GPs may be
sought by the DWP at this stage. GPs have a contractual obligation to complete and return these reports.
Medical examination In the majority of cases, more information will be
needed to be able to assess the claim, and the claimant is then invited for
a face- to- face medical examination assessing mental and physical ability to
work. Groups considered unt to work without medical examination include pregnant women, people with severe physical or learning disability,
and those who are terminally ill.
Classication Based on these assessments people may be placed into one of
3 groups:t to work, work- related activity group, or support group.
Those placed in the work- related activity group take part in work- focused
interviews with personal advisers and are provided with a range of support
to help them prepare for a return to work.
Those placed in the support group have an illness/ disability that has a severe
eect on ability to work. They are not expected to take part in any workrelated activity but can choose to do so if they wish.
Appeals Once a decision has been made about ESA/ Universal Credit,
the individual’s GP is informed and no further sickness certication is
needed. If the claimant disagrees with the decision, he/ she can ask for it to
be reconsidered, and if that fails to alter the decision, can appeal. GPs must
continue sickness certication pending the appeal decision.
Equality Act 2010 An employer has to make ‘reasonable adjustments’
to avoid an employee with an ongoing health problem/ disability being put
at a disadvantage (e.g. adjusting working hours or providing equipment).
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CERTIFYING FITNESS TOWORK
Forms forcertifying incapacity towork
SC1 Self- certication form for people not eligible to claim SSP who wish
to claim ESA/ Universal Credit. Certies rst 7d of illness. Available from
local benets oces and GP surgeries.
SC2 As SC1 but for people who can claim SSP. Available from
employers, local benets oces, and GP surgeries.
Statement of Fitness for Work (Med3) Filled in by a GP or hospital doctor
who knows the patient for periods of incapacity likely to be >7d. In
general practice, usually computer generated and saved directly to the
patient’s medical record.
During the rst 6mo of incapacity can only be issued for a maximum
period of 3mo. Gives the doctor two options:
• The patient is unt for work
• The patient may be t for work— this allows the GP to recommend
circumstances under which the patient may be able to return to work,
e.g. with restricted duties, workplace adaptions, or reduced hours
The form gives space for the GP to record the patient’s functional limitations.
This is designed to allow the employer to make adjustments to facilitate the
employee’s return to work. The GP can also mark on the form whether
there is an intention to review the patient again before return to work.
The Statement of Fitness for Work may be issued:
• On the day of your assessment of the patient (telephone
consultations are acceptable)
• On a date after your assessment of the patient if you think that it would
have been reasonable to issue a Statement on the day of your assessment
• After consideration of a report or other medical record about the
patient from another doctor or registered healthcare professional
Only one Statement of Fitness for Work can be issued per patient per
period of sickness. If mislaid, reissue and mark ‘duplicate’.
0 Employers may not request certication that employees ‘need not
refrain from work’— if required, this should be requested as a private
service from an occupational health physician or GP.
Mat B1 Signed by doctor or midwife. Provided to pregnant women
once within 20wk of estimated date of delivery. Enables her to claim
statutory maternity pay and other benets (E p. 765).
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Private certicates Some employers request a private certicate in
the rst week of sickness absence. They should request it in writing. If the
GP chooses to provide the service, a charge can be made both for a private
consultation and the provision of a private certicate.
Further information
DWP (2016) Fit note:guidance for GPs. M www.gov.uk/ government/
publications/ t- note- guidance- for- gps
Gov.uk Disability rights:employment. M www.gov.uk/ rights- disabled-
person/ employment
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CHAPTER4 Social aspects of primary care
Fitness tomakedecisions
Mental capacity The ability to take actions aecting daily life (e.g. when
to get up, what to wear, what to eat) and/ or make more major decisions
(e.g. where to live, how to manage money).
Mental Capacity Act (2005) Came into force in 2007 in England and
Wales. Similar legislation applies elsewhere in the UK. It species who can
take decisions on behalf of other people and allows people to plan ahead
for a time when they may lack capacity. 5 key principles:
1. Every adult has the right to make decisions and must be assumed to
have capacity to make them unless proved otherwise
2. Every adult must be given all possible help and support to make
decisions, and to communicate those decisions where necessary,
before he/ she can be assumed to have lost capacity
3. Making an unwise decision does not mean that a person lacks capacity
to make that decision
4. Anything done or any decision made on behalf of someone who lacks
capacity must be done in his/ her best interests
5. Anything done or any decision made on behalf of someone who lacks
capacity should be the least restrictive of his/ her basic rights/ freedoms
Assessingcapacity
• Have access to the patient’s records and ideally know the patient
• Seek information from friends, relatives, carers, and/ or the patient’s
independent mental capacity advocate, if one has been appointed
• Examine the patient and assess the type and degree of decit
• 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 relevant information, including the
likely consequences of making/ not making that decision?
• Can the patient retain that information?
• Can the patient use or weigh 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- listed information
0 Even if a proposed action is in the patient’s best interests, do not judge
the patient capable if not clearly the case. Seek a second opinion if in doubt.
Lasting Power of Attorney (LPA) Replaced Enduring Power of
Attorney (EPA) in October 2007. However, people with EPAs in place
can still use them. An LPA is a legal document that lets individuals appoint
someone they trust to make decisions for them. It can be drawn up at
any time whilst the person has capacity but has no legal standing until it is
registered with the Oce of the Public Guardian. Two types:
Property and aairs LPA Allows the ‘attorney’ to make decisions about the
management of money, property, and aairs. Unless specied otherwise,
can be used even when the individual retains capacity.
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FITNESS TOMAKEDECISIONS
Personal welfare LPA Allows the ‘attorney’ to make decisions about healthcare
and welfare, including decisions to refuse or consent to treatment, and decide on place of residence. Only active when the LPA is registered and the
individual lacks capacity to make decisions. The attorney can make decisions
about life- sustaining treatment only if the LPA species that.
Court of Protection If a person, by reason of mental disorder, be-
comes incapable of managing his or her aairs 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 ‘receiver’
to do so. The medical practitioner will be asked to complete form CP3.
Alternatively, if the patient’s aairs are simple (e.g. state pension), direct
arrangements can be made with the relevant authorities.
Testamentary capacity The capacity to make a will. Anyone can make
a will provided they understand the nature and eect of making a will, extent of property being disposed of and claims others may have on that
property, and the decision is not the result of their condition (e.g. due to
a delusion).
0 Decisions do not have to seem rational to others, especially if consistent
with pre- morbid personality.
Consenting to medical treatment E p. 48
Advance decisions Statements about wishes regarding medical treat-
ment in case the individual becomes incapable of making that decision later.
Advance decisions are legally binding.
• Respect any refusal of treatment as long as the decision is clearly
applicable to circumstances, there is no reason to believe the individual
has altered that decision, and the decision was not made under duress
• Advance decisions do not have to be written, except those refusing life-
sustaining treatment which must be:specic to a particular treatment
(e.g. refusal to have CPR); written; signed by the person making the
decision (or a representative if unable to sign) and a witness
• Advance decisions cannot include decisions about treatment the person
would like, only treatment the person refuses, and cannot include
directions to end the person’s life prematurely
• Doctors may not be willing to carry through an advance directive. In
such cases they should refer the patient to another doctor who is
• The BMA recommends doctors should not withhold ‘basic care’ (e.g.
symptom control), even in the face of a directive which species that
the patient should receive no treatment
• Where a formal advance statement is not available, take patients’
known wishes into consideration
Deprivation of Liberty Safeguards (DoLS) E p. 1106
Further information
Oce of the Public Guardian M www.publicguardian.gov.uk
Medical defence organizations
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CHAPTER4 Social aspects of primary care
Fitness todrive
• Driving licence holders (and applicants) have a legal duty to inform the
DVLA of any disability likely to cause danger to the public if they drove.
Driving licencetypes
Group1 Ordinary licence for driving a car/ motorcycle. Minimum age 17y
(16y if disabled). Old licences expire at 70th birthday and then must be renewed 3- yearly. Applicants are asked to conrm they have no medical disability. If so, no medical examination is necessary. New photocard licences
are automatically renewed 10- yearly until age 70y.
Group2 Licences enable holders to drive lorries and buses. Minimum age
21y. Initially valid until 45th birthday then renewable by medical examination every 5y until 65th birthday. >65y renewable annually. Applicants
must bring form D4 (available from post oces) with them. Examinations
take ~½h. Afee may be charged by the GP.
Determining tness to drive Patients with any disorder which may
cause danger to others if they drove should be advised not to drive and to
contact the DVLA. The DVLA gives advice on when they can restart.
Breaching condentiality When a patient continues to drive
despite advice by a doctor to stop, a doctor has an obligation to breach
condentiality and inform the DVLA.
• If the patient does not understand the advice to stop driving—
inform the DVLA immediately
• If the patient does understand, but continues to drive— explain your
legal duty to inform the DVLA. If the patient still continues driving,
oer to refer to a colleague for a second medical opinion— on the
understanding that the patient stops driving in the interim. If all else fails,
inform the DVLA in condence. Before doing this, inform the patient
of your intended actions and consider contacting your medical defence
organization for advice. Once the DVLA has been informed, you should
also write to the patient to conrm disclosure has been made
Visual acuity Drivers must be able to read in good light (with glasses
or contact lenses) a number plate containing gures 79mm high × 57mm
wide at a distance of 20.5m (20m where the characters are 50mm wide).
In addition, Group2 drivers must have corrected vision of ≥6/ 9 (best eye)
and ≥6/ 12 (other eye); they should not drive if uncorrected acuity in either
eye is <3/ 60.
Condition- specic guidance For UK drivers, the DVLA provides de-
tailed condition- specic guidance about tness to drive. Information about
driving is included with the relevant clinical topics in this book. However, as
the DVLA standards are updated every 6mo, always check the most recent
version of the DVLA Assessing tness to drive: a guide for medical profes-
sionals before giving patients advice.
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FITNESS TODRIVE
Multiple medical conditions A combination of medical conditions,
each insucient itself to disqualify from driving, may together render a
person unt or unsafe to drive. If this is the case, advise the patient not to
drive and seek clarication from the DVLA.
• Medication It is an oence to drive or attempt to drive while unt
through the eect of drugs; the law does not distinguish between illicit
and prescribed drugs. GPs prescribing and/ or dispensing medication that
aects ability to drive should advise patients of that risk.
Driving after surgery Drivers do not need to notify the DVLA fol-
lowing surgery unless a condition likely to aect safe driving persists >3mo
(certain exceptions apply for neurological and cardiovascular disorders). It
is the responsibility of the driver to ensure that he/ she is in control of the
vehicle at all times. It might also be advisable for the driver to check with
his/ her insurer before returning to driving after surgery. Consider:
• Recovery from anaesthesia (sedation and cognitive impairment)
• Impairment due to analgesia (sedation and cognitive impairment)
• Physical restrictions due to the surgery or the underlying condition
Disabled drivers Disabled people who want to learn to drive, or re-
turn to driving following onset of their disability, should have an assessment
of their driving ability and/ or advice on controls and adaptations needed.
Licences may be limited to adapted vehicles. Alist of driving assessment
centres can be obtained from Driving Mobility (F 0800 559 3636 M www.
drivingmobility.org.uk).
Seat belt exemption GPs can sign a form to exempt patients (e.g.
those with colostomies) from having to wear a seat belt. Consider very
carefully the reasons for exemption in view of the weight of evidence in favour of seat belts preventing serious harm or injury in the event of collision.
Further information
Department for Transport Medical exemption from compulsory seat belt
wearing:guidance for medical practitioners. M www.gov.uk/ government/
publications/ medical- exemptions- from- compulsory- seat- belt- wearing/
medical- exemption- from- compulsory- seat- belt- wearing- guidance- formedical- practitioners
Driving Mobility F 0800 559 3636 M www.drivingmobility.org.uk
DVLA Assessing tness to drive:a guide for medical pro-
fessionals. M www.gov.uk/ government/ publications/
assessing- tness- to- drive- a- guide- for- medical- professionals
DVLA Medical advisers from the DVLA can advise on dicult issues—
contact:The Medical Adviser, Drivers Medical Group, DVLA, Swansea
SA99 1DA or F 01792 782337 (in Northern Ireland:F 0300 200
7861)or E- mail:medadviser@dvla.gsi.gov.uk (medical professionals only)
Patient information
Gov.uk Driving and medical conditions. M https:// www.gov.uk/ trans-
port/ driving- and- medical- conditions
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CHAPTER4 Social aspects of primary care
Fitness forotheractivities
• Remember— signing a form may result in legal action against you
should the patient not be t to undertake an activity.
• Where possible, include a caveat, e.g. ‘based on information available
in the medical notes, the patient appears to be t to. . .although it is
impossible to guarantee this’
• If unsure, consult your local LMC or medical defence organization
for advice
Fitness to y Passengers are required to tell the airline at the time of
booking about any conditions that might compromise their tness to y.
The airline’s medical ocer must then decide whether to carry them.
Hazards ofying
• Cabin pressure— oxygen levels are lower than at ground level and gas in
the body cavities expands 30% in ight
• Inactivity and dehydration
• Disruption of routine
• Alcohol consumption
• Stress and excitement
Contraindications to ying Table 4.4
Precautions
• Carry all regular medication especially relief medications (e.g.
salbutamol, GTN spray) in the cabin
• For people who have to time their medication carefully, keep to the
times that medication was taken at home for duration of ight, e.g. for
patients with DM— take snacks to eat and take insulin at normal times
• Drink plenty of liquid (non- alcoholic) to prevent dehydration
• Do calf exercises/ get up and walk up and down at intervals to prevent
venous stasis in the legs— those at risk of venous thromboembolism
should wear compression stockings for the ight
• Pre- warn airlines of special needs so that they can accommodate them,
e.g. extra leg room, special diet, oxygen in- ight, transport to/ from
the plane
Further information
Civil Aviation Authority (CAA) Am It to y? M https:// www.caa.
co.uk/ Passengers/ Before- you- y/ Am- I- t- to- y- /
Pre- employment certication It is becoming increasingly common
for GPs to be asked about the ‘medical’ suitability of candidates to
perform a job. This is not part of the GP’s terms of service and therefore
a GP can refuse to give an opinion. In all cases where an opinion is given, a
fee can be claimed. Common examples are:
• Forms for childminders
• Care home sta— proof of ‘physical and mental tness’
• Food handlers— certicates of tness
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FITNESS FOROTHERACTIVITIES
Table4.4 Contraindications toying
Type of condition Contraindications to ying
Respiratory disease Suspected pneumothorax/ pneumomediastinum— patients
Heart disease Patients should not travel if they have unstable angina,
Thromboembolic
disease
Neurological disease Patients should not travel for 3d after stroke, or, if
Infectious disease Patients must not travel with untreated infectious disease
Psychiatric disease Patients should not travel if they have disturbed or
Fractures Flying is restricted for 24– 48h (depending on the length of
Haematological
disease
Pregnancy Most airlines will not carry women >36wk pregnant
Babies <2d old should not y (preferably <7d old)
Ear problems Fl ying with otitis media or sinusitis can result in pain ±
Surgery Patients should not travel <10d after surgery to the chest,
should not y for 14d after complete resolution of
pneumothorax
Chronic lung disease— if a patient can walk >50m or climb
a single ight of stairs without signicant breathlessness,
he/ she should be t to y. Supplementary oxygen can be
provided in ight for patients unable to walk this far but
the patient must pre- book this with the airline and there
is usually a fee
poorly controlled heart failure, or an uncontrolled
arrhythmia, Patients should also refrain from travelling
<10d after uncomplicated MI (3– 4wk if complicated
recovery) and for 3– 5d after angioplasty
Patients should not travel with a DVT before established
on anticoagulants
epileptic, <24h after a grand mal t
unpredictable behaviour that could disrupt the ight
the ight) after the plaster cast has been tted
Anaemia (<7.5g/ dL) and recent sickling crisis may restrict
ying
(3rd trimester if multiple pregnancy) or with history of
premature delivery, cervical incompetence, bleeding, or i
uterine activity
perforation of the ear drum. Patients are advised not to
y until symptoms resolve
abdomen, or middle ear. Other procedures where gas is
introduced into the body also need careful consideration
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Fitness to perform sporting activities E p. 474
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CHAPTER4 Social aspects of primary care
Bereavement, grief, and coping withloss
Models of grief In the traditional model, the bereaved person moves
through phases until ‘recovery’:
• Initial shock Sense of unreality, detachment, disbelief, or ‘numbness’.
Lasts from hours to days
• Yearning Pangs of grief, episodes of intense pining, and a desire to
search interspersed with anxiety, guilt, and self- reproach
• Despair The permanence of the loss is realized. Characterized by
despair, apathy, social withdrawal, poor concentration, and pessimism
about the future
• Recovery Rebuilding of an identity and purpose in life
Recent models Newer models of grief are less linear:grief represents an oscillation between loss- and restoration- focused behaviour, demonstrated by
swings in mood, thoughts, and behaviour between memories of the dead
person and ‘getting on with life’. Avoidance or denial of the loss is common
and a part of the process.
Health consequences ofbereavement
• i mortality (i deaths from CVD, cirrhosis, suicide, accidents)
particularly in rst 6mo. Risk factors:♂ > ♀, age <65y, lower
social class
• Mental health problems Depression, anxiety, i risk of suicide, substance
abuse, identication reaction (hyperchondriacal disorder— symptoms
mimic those of deceased, e.g. chest pain if died from MI), insomnia,
self- neglect
• Physical problems Fatigue, aches, and pains (e.g. headaches,
musculoskeletal pain), appetite change, GI symptoms, d immune
response (i minor infection)
• Others Interference with family life, education and employment, social
isolation/ loneliness, d income
Role of the primary care team Develop a practice policy for be-
reaved patients. Flag notes. Consider sta training and active follow- up of
bereaved patients. If the person who has died is registered with the practice, ensure all medical referrals/ appointments are cancelled.
Bereaved children Children understand what death is by 8y, and even
children of 2– 3y have some understanding of death. Exclusion makes children
isolated and often makes the death of someone they have known more, not
less, painful. Prepare children for a death if possible and give them a chance
to have their questions answered. If a child has problems, seek specialist help.
Bereavement Support Payment Payable if husband, wife, or civil
partner dies aged < state pension age, and either has paid enough National
Insurance contributions, or death was caused by employment. Consists of:
• Initial lump sum, and then
• Up to 18monthly payments
Two rates. The higher rate is payable if there are children <16y (or <20y in full
time education) in the home or a woman whose partner has died is pregnant.
Claims forms can be obtained from JobcentrePlus oces or downloaded
from M www.gov.uk/ bereavement- support- payment. To receive the full
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BEREAVEMENT, GRIEF, AND COPING WITHLOSS
amount, claims should be made <3mo after the death (although will be
accepted for up to 21mo). Further information can be obtained from
F0800 731 0469.
Budgeting Loans for funeral payments E p. 105
Deaths of service personnel Where someone dies during service,
Veterans UK automatically considers whether the death was due to service and whether benets are payable to any dependants. If ex- service
personnel die as a result of illness/ injury sustained while in service, compensation may also be payable. Except for rare exceptions, the Armed
Forces Compensation Scheme generally only applies if someone dies
<7y after leaving the services. Claims must be made <3y after the death.
Further information can be obtained from:F 0808 1914 2 18 M www.gov.
uk/ veterans- uk.
Abnormal grief reactions Whether a grief reaction is normal or
abnormal depends on individual circumstances— personality, situation
surrounding death, and cultural expectations. Recognized patterns of abnormal grief include:
• Inhibited grief— grief is absent or minimal
• Delayed grief— late onset
• Prolonged or chronic grief— inability to rebuild life in any way
If abnormal grief is suspected Monitor carefully. Consider referral for bereavement counselling, e.g. to CRUSE. Consider clinical depression (E
p. 978) or post- traumatic stress disorder (E p. 976). If symptoms are persistent or worsening despite treatment or if there is suicidal risk, refer to the
mental health team for specialist advice.
Risk factors for poor outcome after bereavement
Predisposing factors
• Multiple prior bereavements • Low self- esteem
• Poor social or family support • Being male
• History of mental illness, e.g. depression, anxiety, self- harm
• Ambivalent or dependent relationship with the deceased
Factors associated with the nature of the death
• Sudden or unexpected death
• Suicide
• Death due to unnatural causes e.g. murder, road accident, drowning
• Multiple deaths e.g. natural disaster, terrorist attack
• Avoidable deaths e.g. drug overdose, missed diagnosis
• Death of a child (or for children, death of a parent or sibling)
• Feelings of guilt e.g. if driver of a car involved
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Patient information
CRUSE Bereavement Care F 0808 808 1677 M www.cruse.org.uk
National Association of Widows F 0845 838 2261 M www.nawidows.org.uk
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