These include occupational and sports physicians, prison doctors, forensic medical examiners, doctors in the armed forces, and doctors who work for insurance companies.

General practitioners may also be asked to provide a report about a registered patient to a third party organisation such as an employer, insurance company or benefits agency.

Obtaining consent for the report

Before providing a report to a third party you should satisfy yourself that the patient understands what information is being requested, the reason for the request and the potential consequences of the disclosure of information. Consent should be obtained in writing either from the patient or from their authorised representative, although a doctor can accept an assurance from an officer of a government department or agency or another healthcare professional that such informed consent has been obtained. When obtaining consent the patient should be informed that relevant information cannot be withheld from the report.

Disclosure of reports to patients

A patient has a right to be shown, on request, a medical report written about him for an employer or insurance company. The GMC also advises doctors to offer to show patients their reports or give them copies before disclosure, whether or not the law requires it.

Occupational physicians

Occupational physicians have loyalties both to patients and their employers and the usual therapeutic doctor-patient relationship often does not apply. However, the duty of confidentiality does apply - that is, you must not disclose confidential patient information to employers without the patient's consent, other than in exceptional and justifiable circumstances.

The overriding principle which occupational physicians should apply in producing reports to employers is that of 'no surprises' for the patient. It is important to give the patient a full explanation at the outset about the process, the potential consequences and what happens if they want to amend the report. Consent should be obtained in writing, and clearly demonstrate the patient's wishes regarding every stage of the process.

Where a company provides a clinical treatment service as a benefit to staff, patients have the same right to confidentiality as in any other doctor/patient relationship.

If a patient may pose a serious risk to others through being unfit to work then you may think a limited disclosure may be justified in the public interest.

Sports physicians

Sports physicians employed by clubs also owe a contractual duty to their employers, but have a professional ethical responsibility of confidentiality towards the people they treat. For example, when reporting on a patient's health assessment to the coach or management, you may only disclose the results of the assessment, and not the patient's confidential clinical details. More details can only be disclosed with the patient's consent.

Insurance reports

A doctor who sees an individual for an insurance company - for example, to assess life expectancy - must make sure the person they are examining understands what the consultation is for and get permission in writing before going ahead. The person must understand the reason for the disclosure, the extent of the information to be disclosed and the fact that relevant information cannot be concealed or omitted.

The Association of British Insurers has published principles, agreed with the Information Commissioners Office (ICO), for requesting and obtaining medical information for insurance applications from GPs, in electronic formats. These principles seek to safeguard patient confidentiality, as well as reducing workload. It is recommended that GPs provide focused medical reports rather than sending copies of patients' medical records to insurance companies, which can run the risk of irrelevant information being released, for which patients have not given consent.

Life insurance companies may ask for reports about dead patients, and occasionally ask to see copies of records. Unless the patient gave consent for disclosure after death, you should not agree to the request without the written authority of the personal representative of the deceased's estate. If patients have said that access should not be given after their death, this should also be respected.

Prison doctors

Generally, prison doctors have the same duty of confidentiality to their patients as any other doctor. However, the status of their patients as prisoners may sometimes require disclosure of personal information. For example, Prison Rules state that a medical officer shall report to the governor the case of any prisoner whose health is likely to be injuriously affected by continued imprisonment or any conditions of imprisonment.

Forensic medical examiners (police surgeons)

Forensic medical examiners (FMEs) owe a duty of confidentiality to their patients. FMEs are not obliged to disclose a detainee's medical treatment records routinely to the custody officer without the detainee's consent.

For consent to be valid, the detainee must be capable of giving it. This is important because some detainees may be temporarily incapable - for example if they are drunk or under the influence of drugs at the time they are seen.

You must be satisfied that the detainee fully understands the reason for disclosure, what will be disclosed and to whom, and the fact that relevant information cannot be concealed. The detainee's written consent must be obtained, or that of someone properly authorised to act on his or her instruction.

You have a contractual obligation to tell the police if the person in custody is fit to be detained, interviewed, charged and/or transferred. Medical information that allows the police to care for the detainee properly and is in his or her best interests should be given on a strictly need-to-know basis.

Doctors in the armed forces

Doctors in the armed forces are responsible to their commanding officers for treating sickness and injury, maintaining health and preventing disease. In rare circumstances, you may have to disclose information to the commanding officer without the consent of the patient, or against his or her wishes - for example when the health, security, safety or welfare of the unit or the individual is at risk. If possible, patients should be told in advance that their confidentiality will be breached and why.

Questions and answers

I have been asked to complete an insurance report for a patient who had a transient ischaemic attack (TIA) two years ago. When I contacted him to confirm his consent, I told him that I would have to mention the TIA in the report, along with the rest of his medical history. He has asked me to withhold the information about the TIA because he has been well since and he fears the insurance company may decline his application if I mention it. I have told him that I am not able to withhold any information; is that right?

Yes. You have a duty to complete the report fully and you may not conceal or withhold any relevant information. You will need to explain to the patient that, if he wishes you to complete the report on his behalf, you will have to include the full information about his medical history and that you are not able to withhold any relevant details, even though the TIA happened two years ago.

If he asks you to withhold the information, you will not be able to complete the report. If he agrees and you go ahead, your patient is entitled to see the report under the Access to Medical Reports Act 1988 and the GMC advises doctors to show it to patients before sending it off. If, on seeing the report, the patient disagrees with what you have written, you should not agree to any amendments which would leave the report inaccurate or misleading (including by omission of relevant information), but you can add a commentary stating that the patient does not agree with what you have written.

I have been approached by an insurance company to let them have a report on a patient who took out holiday insurance and who is a well controlled insulin dependent diabetic. On holiday the patient became seriously ill during a bout of gastroenteritis and had to be hospitalised as a result of diabetic keto-acidosis. I don't think that the insurer was aware that she had diabetes and she may not have declared it when taking out the insurance. What should I do?

You first need to contact the patient and seek her consent to prepare the report for the insurance company. You will need to tell her that, if she consents, you have a duty to disclose the relevant medical history as that is what they are seeking. You need to explain to her the potential consequences of such a disclosure and also the fact that you may not conceal or withhold any information.

If she does not agree to you sending the report, you may not do so, but she will need to know that the insurer is likely to draw its own conclusions about the absence of a medical report from the patient's GP. If your patient agrees to the report, you are advised to show it to her in advance and to inform her that you will not make any amendments which would leave the report inaccurate or misleading (including by omission of relevant information), though you can add any comments from her to the form.

I have had a request from an insurance company for details about one of my patients. He was a man in his fifties who died of disseminated carcinoma. It seems he took out the insurance policy shortly before his death, though the insurance company did not contact me for medical information at the time. Should I comply with the request?

The patient may have given the company consent for this disclosure when he applied for the policy and you may wish to check with them that he did so. However, if you are not certain the patient gave consent, or if you believe the consent may not have been valid, then disclosure of the medical report can be authorised by the late patient's personal representative (for example, the executor of his estate). Although your patient is deceased, you still have an obligation of confidentiality to him.

Confidentiality issues in insurance and other reports

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