Confidentiality & Records

Confidentiality (Data Protection Act 1998)

The definition of confidentiality is as follows :-

The principle of keeping secure and secret from others, information given by or about an individual in the course of a professional relationship.

Confidentiality is a legal, professional and ethical responsibility for all clinical staff and those who work with them.

Not only are the principles and practices of confidentiality now enshrined in law as being a fundamental right of individuals – but it is of course also essential to the relationship between individuals and their clinicians. The duty of confidentiality is owed to all patients – including adults with learning disabilities, mental illness or some other incapacity, children whether they are mature or not, and former patients who are now deceased.

Please do not assume you may obtain information regarding a relative because you are related or because a patient falls into one of the categories above. This would be a breach of confidentiality without the consent of the patient.

We realise that this creates problems when a relative enquires as to whether a patient has seen the doctor and is ready to collect. We cannot disclose this information, but a payphone is now available in the waiting area to enable the patient to phone to make necessary arrangements. Only in certain considered circumstances can a breach occur: if it is required by statute; a court order; or it is in the public interest.

Disclosure for non-clinical purposes (without consent) - Data about patients may be used internally for clinical and financial audits, public health surveillance, drugs monitoring, administration and planning; however, all staff involved in these will have signed a confidentiality agreement. Anonymised data may be used for medical research. Patient identifiable information which is necessary to support essential NHS activity which may be used without the consent of patients. This power is reviewed on an annual basis.

Children

Children who are 16 plus are generally assumed to be adults for the purposes of consent to treatment and disclosure of records. Their personal information must therefore not be disclosed to their parents (or anyone else) without their consent.

Children who are under the age of 16, but assessed as being competent to take decisions about their own treatment should have their confidentiality respected and not have personal information passed on to their parents against their will. In all other cases disclosure can be made to anyone who has parental responsibility for the child whether or not they are living with the child.

Both the child’s natural parents have parental responsibility if they were married at the time of the child’s birth. If they were not married at the time of the birth the natural father does not have parental responsibility, unless he makes an application to the court or has a formal document agreed with the mother. Clinical staff do have a right to request confirmation of rights which should be seen as an example of their confidentiality duty and should not be criticised for this.

Unintentional disclosure

Unintentional disclosure also represents a breach of confidentiality and stringent measures are in place to properly protect and secure patient data.

Patient Health Records

All patients have the right of access to their health records following the correct procedure, information regarding this is available on request. We hope this information is reassuring and informative.

The brief for the Health Service is to move towards ‘paperlight’ working, and therefore in line with this the Surgery is fully computerised and the Doctor will work from screen records; however, we back this up on occasion with the use of Lloyd George records which we hold for all patients.