MLACases

[Ethics > Declining Pt Requests]

Sick Note Request - Husband Travelling Abroad (NEW)

Task

Where you are:

FY2 doctor in the GP surgery.

Who the patient is:

35-year-old lady Emma Willis has presented with some concerns. 

Other information you have about the patient:

Her husband is travelling abroad for 2 weeks on a business trip. 

She is the mother of 2-year-old twins.

What you must do:

Take a brief history and negotiate with the mother.  

Patient Information

• Opening sentence: ‘’Doctor, I want a fit/sick note’’.
• Your husband is due to travel abroad to Germany on a business trip for 2 weeks.
• You usually split the childcare of your 2-year-old twins with your husband – you work 2 times a week as a nurse and your husband works 3 times a week. 
• You do not have any family available to look after your children during this period.
• Scenario A: You still have remaining annual leave left at work / Scenario B: You have already used up all of your annual leave for the year. 
• You have not spoken to your manager or the occupational health department.
• You are going through financial difficulties at the moment and cannot afford to take your children to a nursery or to pay for a babysitter.
• You are not currently receiving any benefits such as Income support or Universal Credit.
• All the family is fit and well. 
• You live with your husband and two kids. 

Data Gathering

• GRIPS 1 – How can I help? 
  • → Doctor… I need a fit note.
• Yes sometimes as healthcare professionals we do issue fit notes, but I’ll first need to assess your fitness for work before I can consider whether that’s something I can do for you.  
  
  

Note:

A Statement of Fitness for Work (also known as a Fit note, Sick note or a Med3) is based on an assessment by a healthcare professional about their patient’s fitness for work. 

Legislation requires the healthcare professional to undertake an assessment, either through a face to face, video call, telephone consultation or through considering a written report by another healthcare professional, in order to complete a fit note.

Once issued, the fit note can be used by the individual as evidence for eligibility for Statutory Sick Pay (SSP), or to access health-related benefits.

• Open question: Can you take me through your reasons for needing a fit note?
• Empathy 1 (EVE protocol)
  • Explore - I can see that are clearly in need of some help.
  • Validate - I’m really glad you’ve come in today to discuss this issue with me.
  • Empathise – It does seem like a difficult situation to be in.
  • Finish on a positive note - I’d first like to get a bit more of a background of your situation to see what I can suggest to best help you…
• Closed questions (fill in any important gaps):
  • Mother
    • Current Health: Are you currently suffering from any sickness or ailments?
    • General Health (PMAF): Do you have a history of any health conditions or disabilities?
    • Work:
      • What do you do for work? Is your work able to be performed remotely from home? (not applicable if a nurse)
      • Have you spoken to your manager / occupational health department at your workplace about this issue? What did they say?
        • Have you considered/discussed other paid or unpaid ‘Leave’ options besides Sick Leave such as Annual leave, Parental leave, Time off for dependants, Compassionate leave, etc. 
        • Have you considered/discussed the possibility of… ‘Reasonable adjustments’, such as working from home or changes to shifts/tasks that can be done 
  • Children
    • Current health: Are they currently well?
    • General health (PMAF+BIDNS): Do any of your children have a history of any health conditions or disabilities?
    • Childcare: Who looks after the children? How are duties usually split? Do they visit a nursey or playgroup? Any family that help (or could help) with your childcare?
  • Husband
    • What’s the purpose of your husbands trip? How long will he be gone for? 
  • Finances (signpost)
    • Do you or your husband currently claim any welfare benefits for you or either of your children?
    • Are you experiencing any financial difficulties at the moment? Are you able to afford paying for childcare during this period?
• ICE
  • Ideas – What’s your understanding of fit notes and when they can be issued to patients?
  • Concerns – What’s worrying the most about this situation?
  • Expectations - Other than a fit note which i'll come on to in a moment, was there anything else you were hoping to discuss with me today?  
    
    

Note:

2-year-olds living in England can be entitled to free childcare for a multitude of reasons, including:  

• The children are receiving Disability Living Allowance. 
• The parent/guardian receives Welfare Benefits such as Income Support, income-based Jobseeker’s Allowance (JSA), income-related Employment and Support Allowance (ESA), Universal Credit, and others. 

Management

Key Themes (Overview):

• Decline the Request
  • Say ‘No’ sensitively, Give Reasons, Apologise
• Offer Solutions
  • “Can I suggest”… 
    • Speaking to Management / OH - To explore other paid/unpaid Leave and Reasonable Adjustment options.
    • Seeking Advice from Citizens Advice Bureau - For free financial (benefits) and employment advice.
  • “What I can do”… 
    • Offer Government Leaflet - To make an online application for free childcare.
• Safety netting
  • For if does not come to a solution with these measures
    • Potential child safeguarding issue

Decline the Request

• Thank you answering my questions. I know some of those questions are quite intrusive. 
• I do appreciate that it’s a difficult situation that you’re in at the moment. 
• Say ‘No’ sensitively, Give Reasons, Apologise
  • With regards to the fit note, unfortunately I won’t be able to issue you with a fit note today. 
  • The reason being that we can only issue fit notes for sickness leading you to be unfit to work. Problems with childcare, although very unfortunate, do not qualify as a reason to justify issuing a sick note.
    • I’m really sorry….

Offer Solutions

• Quickly Offer Solution to the problem (don’t dwell on the negative)
  • …However, there may be other avenues where you can receive support to help you with this situation.
  • “Can I suggest”… 
    • Speaking to Management / Occupational Health department
      • Other Leave options: It may be that there are other paid or unpaid Leave options besides paid Sick Leave that you may be eligible for, for example Annual leave or Parental Leave may be something worth exploring.
        • Annual Leave (also known as statutory leave) is a paid period of leave that all workers are legally entitled to receive at least 28 days’ paid annual leave a year. This is the equivalent of 5.6 weeks of holiday.
        • Parental Leave is an unpaid period of leave, however it will ensure that your employment rights (like the right to pay, holidays and returning to a job) are protected. As an employee you have the right to return to your job if you take 4 weeks or less of unpaid Parental Leave .
        • Your management will discuss the different options for you and what you are entitled to.
      • ‘Reasonable adjustments’
        • It may be worth asking if they can make some reasonable adjustments for you as a temporary solution for you such as working from home. 
        • This may require a temporary change to the type of tasks that you do so that you only do tasks that can be done remotely during this period.
    • Seeking Advice from Citizens Advice Bureau
      • This is a free, impartial, confidential service provided by highly trained professional volunteers. They provide information, advice and support on all aspects of life including welfare benefits, employment, legal, community care, etc.
      • It may be that you are eligible for 15 hours of free childcare per week for 38 weeks of the year (during school term time). 
      • Leaflet: Citizens Advice Bureau
  • “What I can do”… 
    • Offer Government Leaflet - provide you with some reading information about how to go about applying for a code to get free childcare. There is no guarantee that your application will be approved but I think it is worth trying.
      • For children aged 2 years - you may be able to get 15 hours free childcare per week for 38 weeks of the year (during school term time). You would however have to pay for extra costs like meals, nappies or trips. 
      • You’ll need to set up a childcare account and it usually takes 20 minutes to apply. You may find out if you’re eligible straight away, but it can take up to 7 days.
      • Leaflet: Gov.uk Online Application for Free Childcare. If your application is approved, you’ll get a code for free childcare to give to your childcare provider.

Safety Netting

• For if does not come to a solution with these measures - If you do not come to a solution with the measures we have discussed, make sure to get in touch and we’ll see what other options we can explore - important as could become a safeguarding issue.
• Apologise again and check expectations – Once again, I’m really sorry about not being able to issue you with a fit note but hopefully, these measures will solve this problem for you. Was there anything else I can help you with today?

Lesson Summary

A 30 year-old woman named Emma Willis has come to the GP surgery with concerns. Her husband is leaving for a two-week business trip to Germany, and she is the mother of 2-year-old twins. She is seeking a sick note because she doesn't have anyone to help with childcare while she is at work (she works as a nurse). She usually shares the childcare duties with her husband.

Approach

• Data Gathering
  • Explain the need for a fitness to work assessment before issuing fit notes
  • Open Question - why needs a fit note
  • Empathy 1 - empathise with her situation
  • Closed questions - to seek more information for assessment
    • Mother (Current Health; General Health/Disabilities; Work - Nature of work and discussions with management)
    • Children (Current Health; General Health/Disabilities, Childcare)
    • Husband (Purpose of trip, Length)
    • Family Finances (Welfare benefits, Current difficulties)
    • ICE
• Management
  • Empathy 2 - thank them for answering difficult/intrusive questions
  • Say 'No' sensitively, Give Reasons & Apologise
  • Offer solutions
    • "Can I Suggest"...
      • Speak to your Manager/OH department (Different Leave options e.g. Annual Leave (or Parental Leave), Reasonable adjustments)
      • Seek advice from Citizens Advice Bureau
    • "What I can do"...
      • Offer Gov.uk Leaflet for free childcare application
  • Aftercare
    • Safety-netting for if does not come to solution
    • Leaflets