There are many core concepts which aid the functioning of the NHS, for instance healthcare professionals are expected to take accountability for their actions; put the patients at the heart of treatment and to provide a comprehensive service which is available to all (NHS,2014). Confidentiality is considered a core concept in the functioning of the NHS and is defined as protecting against the disclosure of patient identifiable information such as the patient’s name, address, postcode and intimate health details to those who may not necessarily be part of the patients care plan or to any individual the patient has not consented to sharing their information with. The rule of confidentiality is followed throughout the patient’s life and after their death (Hawley, 2007). Confidentiality was introduced for those who work In the NHS as they have a duty to safeguard patient’s personal information as it is not only a requirement for those who work for the NHS but it is also a duty under The Data Protection Act. (1998)
It has been argued that confidentiality lays the foundation to how the NHS functions, for instance protecting the private details of a patient is not just a matter of moral respect, it is essential in retaining the important bond of trust. This is particularly complementary to the movement of doctors from a paternalistic approach and towards a more patient orientated approach which aims to value patient’s rights and encourage holistic care (Department of Health, 2001). It has been suggested that valuing confidentiality leads to better patient outcomes. For example, the patient feels more comfortable to openly discuss all aspects of their health with the health care professional and are more likely to seek help in an environment where they feel safe and without fear of the information being leaked and affecting their lifestyle, employment or relationships (Gillon, 1986). In addition, the encouragement of healthcare professionals to be transparent in their decision making and care allows the patient – doctor relationship to be strengthened when based on a confidential approach. Moreover, confidentiality is a concept that is bound by law and hence all health care professionals must work within the law to ensure that they do no harm and work within their agreed codes of practice to provide the best quality of care for their patients.
Therefore, the decision to break confidentiality can be a challenging concept which requires considerable ethical consideration where healthcare professionals are encouraged to assess the wider holistic element of the situation before deciding whether to disclose information. The Caldicott guidelines were introduced to aid in the decision-making process (Caldicott, 2000). The guidelines follow the basis that only a minimum amount of personal identifiable information should be used when absolutely necessary. Another way of deciding to break confidentiality can be assessed using the utilitarian approach- based on the rightness or wrongness of a decision and the impact this could have on the wider society and deontological approach (based on the duties and obligations of the healthcare professional).
It has been suggested that breaking confidentiality can be justified depending on the situation. For example, if an individual has consented for their information to be disclosed and are fully competent in making this decision then it is completely justified to break confidentiality. Without explicit consent, confidentiality can only be breached; if there are reasonable grounds (in order to protect the patient, their family or community); if it is considered democratically necessary (particularly where it might affect others) or if it is proportionate to the need. These reasons allow the protection of patients who could suffer from non-disclosure.
It is also important to consider the utilitarian aspect of breaking confidentiality. For instance, a case study by Seedhouse and Lovett, 1992, in which a doctor faced the ethical dilemma of informing DVLA that the patient had epilepsy is a common scenario that doctors face. In order to justify breaking confidentiality, it is important for doctors to assess the situation whilst taking into account the impact it could have on the patient as well as others. For example, if a patient were to have a fit whilst driving, not only would it result in proceedings with the law or even death of the patient but other drivers could be impacted. When deciding to break confidentiality, doctors often have to compromise between respecting autonomy of the patient with the duty of non-maleficence – where there is a duty to minimise harm. A decision often requires many factors to be taken into consideration with doctors often balancing between their duties in order to achieve the best possible outcome which is in the best interest of not only the patient but also the public. A utilitarian decision is regarded as one that is made If the patient compromises the duty of care to the greater public, in such instance it would be suggested that it is justified to break confidentiality to ensure the greater good of many individuals.
The decision-making process is said to be more complex within the family unit, for example in the case of suspected child abuse (Mason, Laurie and Smith, 2013). Healthcare professionals need to carefully assess the situation before taking further action, for instance care needs to be taken as it could lead to a parent being falsely accused of causing injuries that may innocently be sustained by the child. In the case where a child is being abused and confidentiality is not broken, it can lead to fatal consequences. Therefore, in such cases it is recommended that confidentiality should be broken and is deontologically justified to do so providing the doctor has compelling reason to believe the child is in danger. The Caldicott guidelines agree with the decision to disclose information to social services If the healthcare professional can adequately justify the purpose for which the information is needed.
There have been notable cases where confidentiality was breached without being correctly justified, leading to a loss of trust in healthcare professionals by patients. For example, disclosure of patient information in a lift where the conversation was overheard by members of the public (BMJ, 2003). Although the case was accidental, it is important to understand the repercussions of breaking confidentiality can lead to the patients refusing to seek help as they feel uncomfortable in a setting where their information could potentially be shared with others. Hence, it can be argued that the quality of care that a patient receives is severely compromised. According to the GMC (GMC ,2017) confidentiality standards suggest that if a doctor breaches confidentiality and causes fatal consequences or persistently breaches confidentiality then they will be subject to the risk of losing their registration.
Moreover, another area where breaches in confidentiality are common include paper based patient notes, which are often left on the reception desk – thus allowing potential unauthorised access which could cause serious distress for the patient. To counteract this problem electronic records were introduced whereby the information is encrypted and hence protected from avoidable compromises in confidentiality.
The move from paper based records to electronic records has both advantages and disadvantages for the functioning of the NHS (NHS, 2017). For example, having an electronic system allows access of patient notes to more than one healthcare professional simultaneously which increases the efficiency of the NHS. As well as this, an electronic system reduces the chance of error due to illegibility. It has also been suggested that use of an electronic system further encourages healthcare professionals to follow the Caldicott guidelines on confidentiality. For instance, the administrator is able to identify the user and hence assign the relevant information to them to complete their role thus preventing unnecessary access to the records. Although, there are disadvantages to an electronic system. For example, it can lead to the overreliance on technology which increased the vulnerability of the records to a major breach such as a malware and hence a large-scale breach could compromise patient care with severe delays to the patient’s treatment plan.
To conclude, it is clear that whilst confidentiality is a core concept to how the NHS functions it is also one of the most complex concepts. For instance, doctors have to compromise between principles such as non-maleficence, patient autonomy and confidentiality when deciding to disclose a patient’s personal information. It is also important to note that the choice to disclose such information often has to be justified. Whilst, the Caldicott guidelines offer a general approach to the situation, each unique situation requires health care professionals to use their professional judgement. In addition to this, it is evident that there are often severe consequences to breaking confidentiality with the impact being far reaching, therefore healthcare professionals should continue to be trained regarding when to breach confidentiality.
In my opinion, patient confidentiality is vital for the functioning of the NHS as it allows for the patient to openly disclose information to the healthcare professional and hence reduces the communication barrier between themselves and the professional. Confidentiality links to communication for example, it allows for a patient with a particularly stigmatising condition to openly approach the professional with ease. However, I also believe that the current guidelines set to aid healthcare professionals when breaking confidentiality are as supportive as possible but do not always cater to every situation which is why it is important for the multidisciplinary team to make a grouped decision and treat every situation individually. In terms of situations where confidentiality has been broken for unjust reasons, I believe that the current transparent approach taken by the NHS which allows for accountability to be taken for every action is a fair approach as it increases the patients trust in the system. I also believe that the proposed electronic approach is important for the NHS to implement on a wide scale as I believe the NHS should keep up to date with the technological advances and this will be important for safeguarding confidentiality.
References:
National Health Service. (2014). Understanding The New NHS. [online] Available at: https://www.england.nhs.uk/wp-content/uploads/2014/06/simple-nhs-guide.pdf [Accessed 5 Jul. 2017].
Hawley, G. (Ed.). (2007). Ethics in clinical practice: An interprofessional approach. Harlow: Pearson Education.
Department of Health. (2001). Protecting and Using Confidential Patient Information – A Strategy for the NHS. [online] Available at: https://www.igt.hscic.gov.uk/KnowledgeBaseNew/NHSNumber-Building the information core protecting and using confidential patient information a strategy for the NHS.pdf [Accessed 5 Jul. 2017].
Gillon, R. (1986). Philosophical medical ethics. Chichester: Wiley
(2000). Caldicott Standards and Data Protection Act. [online] Available at: https://www.wcppe.org.uk/sites/default/files/file/NES/CaldicottPrinciples-DataProtectionAct.pdf[Accessed 5 Jul. 2017].
Seedhouse, D., & Lovett, L. (1992). Practical medical ethics. Chichester: Wiley.
Mason, K., Laurie, G., & Smith, A. M. (2013). Mason and McCall Smith's Law and Medical Ethics. Ninth edition. Oxford: Oxford University Press.
Vigod, S. (2003). Privacy of patients' information in hospital lifts: observational study. BMJ, [online] 327(7422), pp.1024-1025. Available at: http://www.bmj.com/content/327/7422/1024 [Accessed 12 Jul. 2017].
General Medical Council. (2017). Confidentiality: good practice in handling patient information [online] Available at: http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp[Accessed 12 Jul. 2017].
National Health Service. (2017). Your health records – The NHS in England – NHS Choices. [online]
Available at: http://www.nhs.uk/NHSEngland/thenhs/records/healthrecords/Pages/overview.aspx[Accessed 5 Jul. 2017].