Medical certificates and reports
July 2004
Patient confidentiality
All information about a patient is confidential including the fact that they have been ill. Just grounds for disclosure are usually that the patient has given consent.
A patient’s signed declaration as valid consent
A patient’s signed declaration on form Med 3 or Med 4 constitutes valid consent. The wording of the
declaration reflects good practice and current law in the sense that disclosure should always be the minimum which is necessary to achieve the objective. A doctor should make as clear as possible the scope of the disclosure to which the patient is agreeing.
Doctors should also be aware that they are only authorised by the current wording on the forms to disclose information that is needed for assessment by the DWP in that particular case and not extraneous details.
Such consent remains valid while the patient’s claim is in effect, and not the period of incapacity, and is only superseded by a further claim.
In some cases consent may have been given by a third party, for instance, a person who is making a benefit claim on behalf of a patient. Doctors must make a judgement as to the validity of this consent and therefore whether to release information would be appropriate. The interests of the patient must always be kept paramount. The publication, Medical Ethics Today – The BMA’s Handbook of Ethics and Law (Chapter 5, Confidentiality), gives further consideration to circumstances where a patient cannot provide consent.
Reports to a medical officer
NHS GPs are under a statutory obligation to provide certain information to a Medical Officer when requested by the Department of Work and Pensions under their contracts. The regulations (see note 1- go there) state:
Reports to a medical officer
80. - (1) The contractor shall, if it is satisfied that the patient consents -
(a) supply in writing to a medical officer within such reasonable period as that officer, or an officer of the Department for Work and Pensions on his behalf and at his direction, may specify, such clinical information as the medical officer considers relevant about a patient to whom the contractor or a person acting on the contractor's behalf has issued or has refused to issue a medical certificate; and
(b) answer any inquiries by a medical officer, or by an officer of the Department for Work and Pensions on his behalf and at his direction, about a prescription form or medical certificate issued by the contractor or on its behalf or about any statement which the contractor or a person acting on the contractor's behalf has made in a report.
The regulations go on to clarify:
(2) For the purpose of satisfying himself that the patient has consented as required by paragraph (1), the contractor may (unless it has reason to believe the patient does not consent) rely on an assurance in writing from the medical officer, or any officer of the Department for Work and Pensions, that he holds the patient's written consent.
The Access to Medical Reports Act 1988 (c28) allows patients access to medical reports written about them for insurance or employment purposes by a medical practitioner who is, or has been, responsible for their clinical care. The General Medical Council publication ‘Confidentiality: Protecting and Providing Information’ of April 2004 clarifies the position with regard to reports provided to the Department of Work and Pensions (formally the Department of Social Security):
‘In some cases other bodies give patients access to reports, for example, the Department of Social Security gives all claimants access to reports made in connection with state benefits. In such cases it is not necessary for you to check patients’ wish to see the report.’
(1) The National Health Service (General Medical Services Contracts) Regulations 2004 and for PMS see regulation 76 of The National Health Service (Personal Medical Services Agreements) Regulations 2004.