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The Social Security (Medical Evidence) Regulations 1976

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Statutory Instruments

1976 No. 615

SOCIAL SECURITY

The Social Security (Medical Evidence) Regulations 1976

Made

21st April 1976

Laid before Parliament

30th April 1976

Coming into Operation

4th October 1976

The Secretary of State for Social Services, in exercise of powers conferred upon him by section 115(1) of, and Schedule 13 to, the Social Security Act 1975 and of all other powers enabling him in that behalf, after reference to the National Insurance Advisory Committee, hereby makes the following regulations:—

Citation, commencement and interpretation

1.—(1) These regulations may be cited as the Social Security (Medical Evidence) Regulations 1976, and shall come into operation on 4th October 1976.

(2) In these regulations, unless the context otherwise requires—

“the Act” means the Social Security Act 1975;

[F1“the Contributions and Benefits Act” means the Social Security Contributions and Benefits Act 1992;]

[F2“personal capability assessment” means the assessment provided for in section 171C of the Contributions and Benefits Act;]

“doctor” means a registered medical practitioner;

[F3“registered midwife” means a midwife who is registered as a midwife with the United Kingdom Central Council for Nursing, Midwifery and Health Visiting under the Nurses, Midwives and Health Visitors Act 1979;]

“signature” means, in relation to any statement or certificate given in accordance with these regulations, the name by which the person giving that statement or certificate, as the case may be, is usually known (any name other than the surname being either in full or otherwise indicated) written by that person in his own handwriting; and “signed” shall be construed accordingly.

(3) Any reference in these regulations to any provisions made by or contained in any enactment or instrument shall, except in so far as the context otherwise requires, be construed as a reference to that provision as amended or extended by any enactment or instrument and as including a reference to any provision which it re-enacts or replaces, or which may re-enact or replace it, with or without modification.

(4) The rules for the construction of Acts of Parliament contained in the Interpretation Act 1889 shall apply in relation to this instrument and in relation to the revocation effected by it as if this instrument, the regulations revoked by it and regulations revoked by the regulations so revoked were Acts of Parliament, and as if each revocation were a repeal.

Textual Amendments

Evidence of incapacity for work and confinement

2.—(1) [F4Subject to regulation 5] [F5where a person claims he is entitled to any benefit, allowance or advantage (other than industrial injuries benefit or statutory sick pay), and his entitlement to that benefit, allowance or advantage depends on his being incapable of work, then in respect of each day until he has been assessed for the purposes of the [F6personal capability assessment], he shall provide evidence of such incapacity][F7—

(a)by means of a certificate in the form of a statement in writing given by a doctor in accordance with the rules set out in Part I of Schedule 1 to these Regulations on the form set out in Part II of that Schedule; or

(b)where a doctor—

(i)has not given a statement under sub-paragraph (a)

of this paragraph since the patient was examined and wishes to give such a statement but more than one day has passed since the examination; or

(ii)advises that the patient should refrain from work on the basis of a written report from another doctor, set out in Part I of Schedule 1A to these Regulations on the form set out in Part II of that Schedule; or]

[F8(c)[F9where the question of whether a person is capable or incapable of work falls to be determined in accordance with the personal capability assessment] and the Secretary of State so requests, a statement in writing given by a doctor in accordance with the rules set out in Part I of Schedule 1B to these Regulations on the form set out in Part II of that Schedule; or]

[F8(d)where it would be unreasonable to require a person to provide a statement [F10in accordance with sub-paragraphs (a) to (c)], such other evidence as may be sufficient to show that he should refrain [F11(or should have refrained)] from work by reason of some specific disease or bodily or mental disablement.]

(2) Every person to whom paragraph (1) applies [F12who has not been assessed for the purposes of the [F13personal capability assessment]] shall, before he returns to work, furnish evidence of the date on which he will become fit to resume work either in accordance with rule 10 of Part I of Schedule 1 to these regulations, or by such other means as may be sufficient in the circumstances of the case.

(3) Every woman who claims maternity benefit shall furnish evidence—

(a)where the claim is made in respect of expectation of confinement, that she is pregnant and as to the stage which she has reached in her pregnancy; or

(b)where the claim is made by virtue of the fact of confinement, that she has been confined,

and shall furnish such evidence [F14by means of a maternity certificate] given by a doctor or by a [F14registered midwife] [F15not earlier than the beginning of the 20th week before the week in which she is expected to be confined,] in accordance with the rules set out in Part I of Schedule 2 to these regulations in the appropriate form as set out in Part II of that Schedule or by such other means as may be sufficient in the circumstances of any particular case.

Textual Amendments

Amendment of the Social Security (Claims and Payments) Regulations 1975

F163.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Textual Amendments

Transitional provisions and revocation

F174.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Textual Amendments

[F18Self-certificate for first 7 days of a spell of incapacity for work

5.—[F19(1) [F20The evidence of incapacity required for the purposes of determining entitlement to a benefit, allowance or advantage referred to in regulation 2(1)]–

(a)for a spell of incapacity which lasts less than 8 days, or

(b)in respect of any of the first 7 days of a longer spell of incapacity;

  • may consist of a self certificate instead of a certificate in the form of a statement in writing given by a doctor in accordance with regulation 2(1).]

(2) For the purpose of this regulation-

  • a "self-certificate" means a declaration made by the claimant in writing, in a form approved for the purpose by the Secretary of State, that he has been unfit for work from a date or for a period specified in the declaration and may include a statement that the claimant expects to continue to be unfit for work on days subsequent to the date on which it is made;

  • [F21“spell of incapacity” has the meaning given to it by section 171B(3) of the Contributions and Benefits Act.]]

Textual Amendments

David Ennals

Secretary of State for Social Services

Regulation 2(1)

SCHEDULE 1

PART IRULES

1.  In these rules, unless the context otherwise requires—

“claimant” means the person in respect of whom a statement is given in accordance with these rules;

“doctor” means a registered medical practitioner not being the claimant;

“doctor's statement” means a statement given in accordance with these rules;

“2 weeks” means any period of 14 consecutive days.

2.  The doctor's statement shall be in the form set out in Part II of this Schedule.

3.  Where the claimant is on the list of a doctor providing general medical services under the National Health Service Act 1946, or the National Health Service (Scotland) Act 1947, [F22or the list of a doctor, or a list held jointly by two or more doctors, performing personal medical services in connection with a pilot scheme under the National Health Service (Primary Care) Act 1997,] and is being attended by such a doctor, the doctor's statement shall be on a form provided by the Secretary of State for the purpose and shall be signed by that doctor.

Textual Amendments

4.  In any other case, the doctor's statement shall be either on a form provided by the Secretary of State for the purpose or in a form substantially to the like effect, and shall be signed by the doctor attending the claimant.

5.  Every doctor's statement shall be completed in ink or other indelible substance, and shall contain the following particulars:—

(a)the claimant's name;

(b)the date of the examination on which the doctor's statement is based;

(c)the diagnosis of the claimant's disorder in respect of which the doctor is advising the claimant to refrain from work or, as the case may be, which has caused the claimant's absence from work;

(d)the date on which the doctor's statement is given;

(e)the address of the doctor,

and shall bear, opposite the words “Doctor's signature”, the signature of the doctor making the statement written after there have been entered the claimant's name and the doctor's diagnosis.

6.  Subject to rules 7 and 8 below, the diagnosis of the claimant's disorder in respect of which the doctor is advising the claimant to refrain from work or, as the case may be, which has caused the claimant's absence from work shall be specified as precisely as the doctor's knowledge of the claimant's condition at the time of the examination permits.

7.  Where, in the doctor's opinion, a disclosure to the claimant of the precise disorder would be prejudicial to his well-being, the diagnosis may be specified less precisely.

8.  In the case of an initial examination by a doctor in respect of a disorder stated by the claimant to have caused incapacity for work, where—

(a)there are no clinical signs of that disorder, and

(b)in the doctor's opinion, the claimant need not refrain from work,

instead of specifying a diagnosis “unspecified” may be entered.

9.  A doctor's statement must be given on a date not later than one day after the date of the examination on which it is based, and no further doctor's statement based on the same examination shall be furnished other than a doctor's statement by way of replacement of an original which has been lost or mislaid, in which case it shall be clearly marked “duplicate”.

10.  Where, in the doctor's opinion, the claimant will become fit to resume work on a day not later than 2 weeks after the date of the examination on which the doctor's statement is based, the doctor's statement shall specify that day.

11.  Subject to rules 12 and 13 below, the doctor's statement shall specify the minimum period during which, in the doctor's opinion, the claimant should, by reason of his disorder, refrain from work.

12.  The period specified shall begin on the date of the examination on which the doctor's statement is based and shall not exceed 6 months unless the claimant has, on the advice of a doctor, refrained from work for at least 6 months immediately preceding that date.

Where

13.—(a) the claimant has, on the advice of a doctor, refrained from work for at least 6 months immediately preceding the date of the examination on which the doctor's statement is based, and

(b)in the doctor's opinion, it will be necessary for the claimant to refrain from work for the foreseeable future,

instead of specifying a period, the doctor may, having regard to the circumstances of the particular case, enter the words “until further notice”.

14.  The Notes set out in Part III of this Schedule shall accompany the form of doctor's statement provided by the Secretary of State.

15.  A doctor may, having regard to the circumstances of the particular case, indicate on the doctor's statement that the claimant should be considered for vocational rehabilitation.

PART IIFORM OF DOCTOR'S STATEMENT

DOCTOR'S STATEMENT

PART IIITHE NOTES

The following notes shall accompany the form of doctor's statement provided by the Secretary of State:—

On the doctor's statement:—

(1) After the words “you should refrain from work for”, the period entered must not exceed 6 months unless the patient has, on the advice of a doctor, already refrained from work for a continuous period of 6 months.

(2) After the words “you should refrain from work until”—

(a)if the patient is being given a date when he can return to work the date entered should not be more than 2 weeks after the date of the examination;

(b)if the patient has already been incapable of work for at least 6 months and recovery of capacity for work in the foreseeable future is not expected “further notice” may be entered.

Regulation 2(1)

[F23SCHEDULE 1A

Textual Amendments

PART Irules

1.  In these rules, unless the context otherwise requires—

“claimant” means the person in respect of whom a statement is given in accordance with these rules;

“doctor” means a registered medical practitioner not being the claimant;

“special statement” means the form prescribed in Part II of this Schedule.

2.  Where a doctor advises a claimant to refrain from work on the basis of a written report which he has received from another doctor or where a doctor has not issued a statement since the claimant was examined and he wishes to issue a statement more than a day after the examination he shall use the special statement.

3.  The special statement shall be completed in the manner described in paragraph 5 of Part I to Schedule 1.

4.  Subject to rules 5 and 6 below, the diagnosis of the claimant’s disorder in respect of which the doctor is advising the claimant to refrain from work or as the case may be, which has caused the claimant’s absence from work shall be specified as precisely as the doctor’s knowledge of the claimant’s condition permits.

5.  Where, in the doctor’s opinion, a disclosure to the claimant of the precise disorder would be prejudicial to his well being, the diagnosis may be specified less precisely.

6.  In a case of a disorder stated by the claimant to have caused incapacity for work, where—

(a)no clinical signs have been found of that disorder, and

(b)in the doctor’s opinion, the claimant need not refrain from work, “unspecified” may be entered.

7.  Part B of the special statement must only be given on a date not later than one month after the date of the written report on which the special statement is based and that part shall only be used where the claimant is being advised to refrain from work for a specified period of not more than one month.

PART IIform of special statement]

Regulation 2(1)(c)

[F24SCHEDULE 1B

Textual Amendments

PART IRules

1.  In these rules, unless the context otherwise requires—

“claimant” means the person in respect of whom a statement is given in accordance with these rules;

“doctor” means a registered medical practitioner not being the claimant;

“[F25personal capability assessment statement]” means a statement given by a doctor in accordance with these rules.

Textual Amendments

2.  Where the Secretary of State has requested that the claimant provide an [F25personal capability assessment statement], that statement shall be provided in the form prescribed in Part II of this Schedule notwithstanding that the claimant has already provided a statement in accordance with Schedule 1 or 1A.

Textual Amendments

3.  The [F25personal capability assessment statement] shall be completed in accordance with rules 3, 4, 5 [F26and 9 to 13] of Part I to Schedule 1.

Textual Amendments

4.  Subject to rule 5 below, the diagnosis of—

(a)the disorder in respect of which the doctor is advising the claimant to refrain from work or, as the case may be, which has caused the claimant’s absence from work; and

(b)any other condition which could affect the claimant’s capacity for work,

shall be specified as precisely as the doctor’s knowledge of the claimant’s condition at the time of the examination permits.

5.  Where, in the doctor’s opinion, a disclosure to the claimant of the precise disorder would be prejudicial to his well being, the diagnosis may be specified less precisely.

6.  The notes set out in Part III of this Schedule shall accompany the form of doctor’s statement provided by the Secretary of State.

PART II

FORM OF DOCTOR'S STATEMENT

THIS FORM SHOULD NOT BE USED FOR PEOPLE CLAIMING STATUTORY SICK PAY FROM THEIR EMPLOYER
Doctor's Statement
In confidence to Mr/Mrs/Miss/Ms__________________________________________________________
Note for Doctor - we are making an assessment of your patients eligibility for Incapacity Benefit and other state benefits under the terms of the [F27personal capability assessment]. Please complete the following boxes
Main diagnosis (be as precise as possible)__________________________________
Other diagnosis ___________________________________________________________________________
Doctor's remarks

(Including comments on the disabling effects of the condition, treatment and progress - accuracy and detail will avoid requests for completion of a medical report).

Note for Doctor - While the [F27personal capability assessment] is being carried out, we need evidence that your patient should refrain from his usual occupation. Please provide the following information (which will not be part of the [F28personal capability assessment] ).
I am issuing the following statement based upon the current guidance to certifying medical practitioners. I examined you today / yesterday and advised you that:

(a) You need not refrain from your usual occupation

(b) You should refrain from your usual occupation

For (Insert period) _________________

Or until ___________________________

Doctor's

Signature

Date of

signing

Form Med 4

Textual Amendments

PART IIIThe Notes

The following notes shall accompany the form of doctor’s statement provided by the Secretary of State:

1.  After the words on the doctor’s statement “you should refrain from your usual occupation”—

(i)if the patient is being given a date when he can return to work, the date entered should not be more than 2 weeks after the date on which the statement is issued;

(ii)if recovery of capacity for work in the foreseeable future is not expected, “further notice” may be entered.

2.  The “remarks” box should be used to provide additional information; including further details of diagnosed conditions, the disabling effect of such conditions, and notes on the patient’s treatment and progress. Accuracy and detail will avoid requests for completion of a medical report.

3.  The “remarks” box should also be used to state whether or not the patient is able to travel a reasonable distance to a medical examination as a result of his condition. If no entry is made, it will be assumed that the patient can travel.

4.  This form of doctor’s statement should not be used where the patient is claiming statutory sick pay from their employer. Form Med 3 should be used for that purpose.]

Regulation 2(3)

[F29SCHEDULE 2

Textual Amendments

PART Irules

1.  In these rules any reference to a woman is a reference to the woman in respect of whom a maternity certificate is given in accordance with these rules.

2.  A maternity certificate shall be given by a doctor or registered midwife attending the woman and shall not be given by the woman herself.

3.  The maternity certificate shall be on a form provided by the Secretary of State for the purpose and the wording shall be that set out in the appropriate part of the form specified in Part II of this Schedule.

4.  Every maternity certificate shall be completed in ink or other indelible substance and shall contain the following particulars—

(a)the woman’s name;

(b)the week in which the woman is expected to be confined or, if the maternity certificate is given after confinement, the date of that confinement and the date the confinement was expected to take place F30...;

(c)the date of the examination on which the maternity certificate is based;

(d)the date on which the maternity certificate is signed; and

(e)the address of the doctor or where the maternity certificate is signed by a [F31registered midwife the personal identification number given to her by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (“UKCC”) on her registration in Part 10 of the register maintained under section 10 of the Nurses, Midwives and Health Visitors Act 1979 and the expiry date of that registration],

and shall bear opposite the word “Signature”, the signature of the person giving the maternity certificate written after there has been entered on the maternity certificate the woman’s name and the expected date or, as the case may be, the date of the confinement.

Textual Amendments

F30Words in Sch. 2 Pt. I para. 4(b) omitted (1.11.1991) by virtue of The Social Security (Miscellaneous Provisions) Amendment Regulations 1991 (S.I. 1991/2284), regs. 1, 21(a)

5.  After a maternity certificate has been given, no further maternity certificate based on the same examination shall be furnished other than a maternity certificate by way of replacement of an original which has been lost or mislaid, in which case it shall be clearly marked “duplicate”.

[F32PART IIFORM OF CERTIFICATE

Textual Amendments

MATERNITY CERTIFICATE

Please fill in this form in ink

Name of patient _________________________________

Fill in this part if you are giving the certificate before the confinement.

Fill in this part if you are giving the certificate after the confinement.
Do not fill this in more [F33than 20 weeks] before the week the baby is expected.I certify that I attended you in connection with the birth which took place on ......./........../....... when you were delivered of a child [__] children.
I certify that I examined you on the date given below. In my opinion you can expect to have your baby in the week that includes ......./........../........In my opinion your baby was expected in the week that includes ......./........../........

"Week": This means the 7 days beginning on a Sunday.

Date of examination ......../........../........Registered midwives:
Please give your UKCC Personal Identification Number and the expiry date of your registration with the UKCC.
Date of signing ......./........../........___________________________________
Signature:

Doctors:

Please stamp your name and address here if the form has not been stamped by the [F34Health Authority] in whose medical list you are included]]

Textual Amendments

EXPLANATORY NOTE

The Regulations provide for the manner in which evidence of incapacity for work or of expected confinement or confinement is to be given for the purposes of a claim for benefit under the Social Security Act 1975 for which evidence is required. The Regulations replace the Social Security (Medical Certification) Regulations 1975 (“the 1975 Regulations”) which are revoked.

The Regulations and Rules in Schedule 1 prescribe a certificate in the form of a doctor's statement in which the issuing doctor advises the claimant that he need not refrain from work or, as the case may be, that he should refrain from work for a period of up to 6 months, or longer in certain circumstances. Certificates for the purposes of maternity benefit are prescribed in Schedule 2 and correspond to those in the 1975 Regulations. The Regulations amend the Social Security (Claims and Payments) Regulations 1975 so that a doctor's statement and a special statement based on a written report from another doctor may be accepted for the purposes of forward allowances of certain benefits.

The Report of the National Insurance Advisory Committee dated 10th March 1976 on the draft of these Regulations referred to them is contained in House of Commons Paper No. 349 (Session 1975–76) published by Her Majesty's Stationery Office.

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