SJT notes

You should answer what you should do in the scenario described, not what you would do

What does the SJT measure?

1. Commitment to Professionalism
2. Coping with Pressure
3. Effective Communication
4. Learning & Professional Development
5. Organisation & Planning
6. Patient Focus
7. Problem Solving & Decision Making
8. Self-Awareness & Insight
9. Working Effectively as Part of a Team

Patient Focus
o Ensures patient is the focus of care
o Demonstrates understanding

Plan
1. Read everything the GMC produced – brief notes
2. Read the SJT monograph notes
3. Complete all of the Oxford Handbook of SJT Qs a couple of times
4. Passmedicine SJT
5. Do the practice paper three times – once every day
6. Emedica?

Law
1. Mental Capacity Act - done
2. Mental Health Act - done
3. Fraser guidelines - done
4. Gillick Competency - done
5. Euthanasia

Priority List
1. Patient Safety
2. Patient Autonomy
3. Escalate within your team
4. Escalate to another team
5. Look after your own health
6. Don’t upset the patient
7. Don’t upset your team
8. Don’t upset another team
9. Go to teaching
10. Social life

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Aggressive patient/relative
1. Empathise
2. Ensure own safety
3. Try to calm down

Mental Health Act

o Section 2
o Why – for assessment & treatment
o How long – up to 28 days
o Application – By an approved MHP with the recommendation of 2 doctors
o Section 3
o Why – for treatment
o How long – up to 6 months
o Application – By an approved MHP with the recommendation of 2 doctors
o Section 5(2)
o Why – To hold someone as an inpatient until a MHA assessment
o How long – up to 72 hours
o Application – By 1 fully registered doctor (NOT F1)
o Section 136
o Why – To remove someone who appears to be mentally disordered from a
public place to a place of safety
o How long – Up to 72 hours
o Application – By 1 police officer

Mental Capacity Act

o Understand
o Retain
o Weigh
o Communicate

Are they able to understand the information they need to make the decision?
Are they able to retain this information?
Are they able to weigh that information?
Are they able to communicate their decision?

If the answer to any of these is No, they are not capable of making this decision at this time

Are people with a mental disorder always incapable of making their own decisions? NO

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Gillick competence

Victoria Gillick challenged Department of Health guidance which enabled doctors to provide
contraceptive advice and treatment to girls under 16 without their parents knowing. In 1983
the judgement from this case laid out criteria for establishing whether a child under has the
capacity to provide consent to treatment; the so-called ‘Gillick test’. It was determined that
children under 16 can consent if they have sufficient understanding and intelligence to fully
understand what is involved in a proposed treatment, including its purpose, nature, likely
effects and risks, chances of success and the availability of other options.

If a child passes the Gillick test, he or she is considered ‘Gillick competent’ to consent to
that medical treatment or intervention. However, as with adults, this consent is only valid if
given voluntarily and not under undue influence or pressure by anyone else. Additionally, a
child may have the capacity to consent to some treatments but not others. The
understanding required for different interventions will vary, and capacity can also fluctuate
such as in certain mental health conditions. Therefore each individual decision requires
assessment of Gillick competence.

If a child does not pass the Gillick test, then the consent of a person with parental
responsibility (or sometimes the courts) is needed in order to proceed with treatment.

Fraser guidelines

The ‘Fraser guidelines’ specifically relate only to contraception and sexual health. They are
named after one of the Lords responsible for the Gillick judgement but who went on to
address the specific issue of giving contraceptive advice and treatment to those under 16
without parental consent. The House of Lords concluded that advice can be given in this
situation as long as:

1. He/she has sufficient maturity and intelligence to understand the nature and
implications of the proposed treatment
2. He/she cannot be persuaded to tell her parents or to allow the doctor to tell them
3. He/she is very likely to begin or continue having sexual intercourse with or without
contraceptive treatment
4. His/her physical or mental health is likely to suffer unless he/she received the advice or
treatment
5. The advice or treatment is in the young person’s best interests.

Health professionals should still encourage the young person to inform his or her parent(s)
or get permission to do so on their behalf, but if this permission is not given they can still
give the child advice and treatment. If the conditions are not all met, however, or there is
reason to believe that the child is under pressure to give consent or is being exploited, there
would be grounds to break confidentiality.

3
 Fraser guidelines originally just related to contraceptive advice and treatment but, following
a case in 2006, they now apply to decisions about treatment for sexually transmitted
infections and termination of pregnancy.

Under 13
There is no lower age limit for Gillick competence or Fraser guidelines to be applied. That
said, it would rarely be appropriate or safe for a child less than 13 years of age to consent to
treatment without a parent’s involvement. When it comes to sexual health, those under 13
are not legally able to consent to any sexual activity, and therefore any information that
such a person was sexually active would need to be acted on, regardless of the results of the
Gillick test.

16-17 year olds

Young people aged 16 or 17 are presumed in law, like adults, to have the capacity to
consent to medical treatment. However, unlike adults, their refusal of treatment can in
some circumstances be overridden by a parent, someone with parental responsibility or a
court. This is because we have an overriding duty to act in the best interests of a child. This
would include circumstances where refusal would likely lead to death, severe permanent
injury or irreversible mental or physical harm.

Under 16: safeguarding considerations

If a young person under the age of 16 presents to a health care professional, then discloses
a history raising safeguarding concerns:

 If they are not deemed to be Gillick competent, the health professional is obliged to raise
the issue as a safeguarding concern and escalate their concerns through the safeguarding
process
 If they are deemed to be Gillick competent and disclosure is considered essential to protect
them from harm or to be in the public interest, the health professional should escalate
concerns through the safeguarding processes
 In both cases, the health professional should inform the young person of this action, unless
doing so could pose significant additional risk for their safe care.

It is reasonable for the local authority or police to decide whether it is appropriate to inform
the parents of the concerns raised. In some circumstances this may not be in the best
interest of the young person.

Summary

Gillick competence is the principle we use to judge capacity in children to consent to

medical treatment. Fraser guidelines are used specifically for children requesting
contraceptive or sexual health advice and treatment. Where a person under the age of 16 is
not Gillick competent and therefore is deemed to lack the capacity to consent, it can be
given on their behalf by someone with parental responsibility or by the court. However,
there is still a duty to keep the child’s best interests at the heart of any decision, and the
child or young person should be involved in the decision-making process as far as possible.

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Commitment to professionalism
 Issues of confidentiality
o Know when to break it
 Challenging inappropriate behaviour
 Commitment to learning
 Taking responsibility for own actions
o Take ownership of your actions, apologise, correct it, learn from it
o Do not cover it up
 Professional integrity / probity
o You are honest when dealing with patients, relatives, colleagues
o You don’t misuse your position as a doctor
 Ethical behaviour / principles

Coping with pressure

 Recognise own limitations
 Calm under pressure
 Prepared to ask for help
 Manages uncertainty
 Deals with stress effectively
 Deals with confrontation appropriately

Effective Communication
 Demonstrates sensitivity
 Adjusts communication to suit situation
 Keeps patients / colleagues up to date
 Creates a safe environment for patients
 Seeks clarification when necessary (abbreviations etc)
 Maintains high standard of written communication
 Clear & understandable use of language

Patient Focus
 Demonstrates empathy & respect
 Establishes rapport
 Polite & courteous with open manner
 Provides reassurance when appropriate (not false)
 Considers patient safety at all times
 Patient centred approach
 Offers support / availability to patient

Working as part of a team

 Understands roles of other team members
 Able to learn from others / take direction
 Asks for advice / support appropriately
 Empathetic towards other team members
 Able to adapt own role within team
 Good working relationship with others

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  Shows respect for colleagues
 Shares knowledge / expertise (e.g. teaching medical students)

Tips
 Highlight the key words of the scenario
 Picture the choices in your head and think about the consequences
 Make logical deductions, not far-fetched assumptions

Ranking subtypes
 Rank actions – appropriateness of actions
 Rank considerations – importance of considerations to manage situation
 Rank order – order in which to do tasks
o All will be most likely correct
 Rank agreement – extent to which you agree with statements
o How much do you agree with the following statement

PD section 2
 Asked to select 3 answers
 Most appropriate COMBINED response
o Most appropriate actions
o Most important considerations
 Cannot discuss confidential info (e.g. results) when patient’s relatives are present
(even next of kin), assuming they are fine with it
 Can assume its ok if the pt e.g. brings his wife to the clinic

Test to do before putting pencil to paper

1. Read the three choices back together with the word “AND” between them and ask
yourself if it makes sense

Tips – General
 Read each scenario carefully
 Highlight key words or phrases
 Keep to time - <2 min per question

Tips – Section 1 Ranking

 Read all answer options before ranking
 Remember they are not asking which is the RIGHT or WRONG answer
 Rank from BEST to WORST
 Compare to option ABOVE and BELOW
 Potential for harm / potential for benefit
 Read the stem carefully – new subtypes

Tips – Section 2
 3 choices COMBINED

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  Look for pairs / triples – 1 ONLY from a set
 Read back your choices together – does it make any sense?
Tips – Consider the following:
 Time
 Who to involve (more expertise or share the workload? – F1)
 Formal or informal approach
 Issues for you, patients, team, colleague (don’t cover up)
 Lines of authority
o Ask a nurse to administer IV antibiotics, she didn’t, go ask the nurse why,
maybe you missed an allergy
o Don’t call the boss
 Ethics
o What does and what doesn’t constitute breach of confidentiality
o Especially safe guarding issues
 Good Medical Practice

Core staff in hospital for the Foundation SJT exam

SJT – how to prepare

 Know the FY1 domains / attributes
 Read Good Medical Practice
 Read GMC ethical guidance
 Understand differences between question types
 Practice questions
o Do less questions but spend more time understanding why the order is the
order
o If you get it wrong, why did I miss it? And feel comfortable with knowing
reasons

Useful resources

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  Official FP practice papers
 30 question SJT paper (no new questions, released the first year)
 GMC Good medical practice in action – interactive scenarios
 SJT monograph (he will summarise it for us)
o But at the back of it, each subdomain is summarised, this is worth reading
 We will email you further reading and links
 125 SJTs on Emedica

Core Knowledge – FY1 SJT

 Ethical principles
 Confidentiality
 Capacity
 Informed consent
 GMC duties of a doctor
 GMC key ethical guidance

Ethical principles
 Autonomy – right to self determination (pts who have capacity)
o I do not want this treatment
o Patient with autonomy has the right to make unwise choice
 Beneficence – act to do good
o Explain the benefits a procedure
 Non-Maleficence – avoid doing harm
o But also explain the risks, and offer it as an option for them to exercise their
autonomy
 Justice
o Individual level – treat patients fairly, free of discrimination and prejudice
 Ethinicity, sexual orientation etc
 You treat people based on CLINICAL NEED
o Distributive justice – use of resources
 Sometimes you might make a decision which impacts the availability
of resources for other people
 E.g. one scanner – only a certain number of people, if you send
someone who doesn’t need, this might result in someone needing it
getting bumped till the next day

Confidentiality
 Right to confidentiality protected – all patients
 Disclosure of confidential information
o If required by law
 Notifiable diseases
 They might need to test anyone who they work with and live
with

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  Their right to confidentiality outweighed by your duty to obey
the law and to protect the public (prevent an outbreak)
o Sorry you are not happy about it, but I have to tell a
public health consultant
o If I don’t do this, I might have to be prosecuted
 Ordered by a court
 Must obey the law, otherwise I will be in contempt of court
o Risk of death or serious harm
 Patient
 Third party
 DVLA – pt with epilepsy, refuses to inform DVLA and stop
driving
 Must tell the DVLA, but inform the patient before doing so
 Would this be preventing a risk of death or serious harm?

Capacity
 The ability to make own decisions
 Must have capacity to exercise your autonomy
 If you lack capacity, you cannot exercise your autonomy
 By default, all adults deemed to have capacity, unless we have evidence they lack it
o Us disagreeing with their decision does not mean they don’t have capacity
 Children < 16 – by default – lack capacity
o Unless assess them as Gillick competent
 Mature, understand the proposed decision, can weigh up the risks
and benefits – then you treat them as an adult – can give consent
 Capacity judged at the POINT OF CARE when a decision is being made
o Time specific, person specific

Consent
 Has to be INFORMED to be valid
 Patient must have CAPACITY
 Decision must be made voluntarily – no pressure, no duress
 Information on risks & benefits
 Montgomery vs Lanarkshire HB 2015
o Reasonable care to ensure patient is aware of any material risks + reasonable
alternatives
 Bolam test no longer applies to consent
o A body of your peers feels that this is reasonable
o If they did, you passed the test, even if you were negligent
o Bolam vs Friern Hospital (1957)
 “If a doctor reaches the standard of a responsible body of medical
opinion, he is not negligent”
 Applies to diagnosis, investigation, management
 Does NOT apply to CONSENT anymore, but does to everything else

The best person to consent a patient is the one doing the procedure

9
  Second best – someone who knows how to do it
 Reality in NHS (not for SJTs, for real work as a junior doctor) – junior doctors
consenting patients, because registrars and consultants were busy
 If you are consenting a patient for a procedure, read up on all the risks as much as
you can
 If you are not confident that you don’t understand all of the risks, ask your registrar
or consultant so that you are confident
 If you are not confident, politely ask them to do the consent
 If you fuck up, you will not be protected by Bolan, because under Montgomery any
material risks should have been discussed

Duties of a doctor
 Make the care of your patient your FIRST concern
 Protect and promote the health of PATIENTS & the PUBLIC
 Provide a good standard of practice & care
o Keep up to date, continue learning, evidence-based medicine
 Treat patients as individuals & respect their dignity
 Work in partnership with patients
 Be honest & open & act with integrity

GMC Ethical Guidance – read these

 Confidentiality - covered
 Child protection / care of younger people
 End of life care
 Personal beliefs & medical practice
 Raising concerns
 Prescribing
 Consent – covered
 Maintaining boundaries

Child protection
 Report SUSPECTED neglect / abuse
 DO NOT WAIT FOR PROOF – by doing this you expose the child to a longer period of
harm
o Someone who abused child once may have done it previously and may do it
again
o The longer you leave it, the greater the risk
 Every place has a child protection lead
 Any one of us can make a direct referral to child protection / safeguarding
 HOWEVER
o As an F1 – your best option is to discharge your duty of care by telling your
CONSULTANT (Clinical supervisor)
o ALWAYS INVOLVE SENIOR DOCTORS
o By directly referring, you are bypassing your consultant, who is in charge of
care of the patient

10
 o If a child is old enough to understand, you need to inform them that you will
tell someone more senior or that safeguarding might get involved
o You should also tell their parents, unless it would put the child at an
increased risk

End of life care

 Provide same quality of care as any other patient – part of Justice
 Act in a way of presumption in favour of prolonging life
 DNA orders should involve the patient – LEGAL DUTY
o Tracey case 2014
o Exception if “convincing reasons not to involve”
o Avoiding potential distress not a valid reason
o Valid advanced refusals binding
 Valid advanced refusals binding in law
o If someone says I do not wish to be resuscitated – you cannot resuscitate
them
o Same goes for blood transfusion

Personal beliefs & medical practice

 Advise patients of their right to see another doctor where beliefs may cause conflict,
e.g. termination of pregnancy
 Provide high quality care despite conflicts
 Respect patient’s right to practice their beliefs, e.g. Jehovah’s witness / blood
 Can be as third-party questions
Doctor cannot say I don’t believe in termination, get out
 Because of my beliefs I am worried I might not be able to be objective. Would you like
another doctor? And hand over the necessary details of the patient.

If you know a Jehovah’s witness but aren’t sure about their stance on blood transfusion and
they are bleeding out, you must transfuse. (if they understand the risks and have capacity) –
in favour of prolonging life

If they understand they will bleed out and die – cannot transfuse them  assault & illegal
 You cannot impose your beliefs on others
 Do not make assumptions

Raising concerns
 Duty to raise concerns re: patient safety
o Colleague – on drugs or intoxicated
 Practice of colleague
 Systems, policies, procedures – medical staffing
o Don’t just say no, raise concern so the system can take notice of it
 As an FY1, raise concerns with senior staff

Prescribing
 Prescribe safely – dosages / contraindications from BNF – check BNF

11
  Ensure prescriptions based on third party advice are appropriate
o Drugs way outside its range – e.g. in palliative care – worried about
symptomatic relief, not potential long-term side effects
o Using drugs outside of their license
 Ketamine – tranquilizer / anaesthetic
 In palliative care, ket sometimes used to treat bone mets or
mixed tissues type pain that hasn’t responded to anything
o You, as an FY1, cannot prescribe both of these types
 Ensure prescriptions based on third party advice are appropriate
o Ask the registrar to come review the patient and their particular drug
o Make sure you understand the reasoning and what they are for and that you
can justify it!!!!!!
o If you don’t, learn it or make them sign it – neznalost neomlouva
o If you sign and they made a mistake, it’s your ass on the line
 Avoid prescribing for yourself or those close to you
o To prevent abuse of medications (benzoes, morphine etc)

Maintaining boundaries
 Avoid improper relationships with patients
o Current patients + their family
o Former patients if vulnerable
 Offer chaperones for intimate exams
o Not a family member of the patient!!!
o There to protect the patient and to protect you, family members could
collude to sue you
o Anyone who was trained to be a chaperone
o Best practice
 Inside the curtain and observe the examination
 Document the name and the job role of the chaperone and they
should input a separate entry
o People get in trouble when they take shortcuts
 Report concerns of improper relationships
o Doesn’t matter who
o Not just physical, intimate or romantic, but also financial
o Asking them to see them in their private hospital etc

Social Media
 If posting on a medical topic as a Dr (if it suggests you are a doctor), identify yourself
by name
 Do not mix professional & personal roles
 Do not identify specific patients – even in closed groups
 Interactions with patients on social media considered in same light as in person (by
GMC)

Financial issues
 Do not encourage personal gifts or loans
 Do not pressure patients to donate money

12
  Unsolicited gifts may be accepted
o If it does not alter care / result in advantage
 Gifts should NOT be accepted if they may be perceived as an abuse of trust
 But sometimes refusing gifts may be very upsetting
 In some situations, cash can be fine and there is no limit
 E.g. if patient is leaving a hospital, it might be fine, but it’s more difficult at a GP
practice (may alter care)

Every hospital – registered gifts – worth of 100 GBP or more – you REGISTER it

Professional Attribute Behavioural Descriptors

1. Commitment to
Professionalism
Displays honesty, integrity and
aware- ness of confidentiality
and ethical issues. Is
trustworthy and reliable.
Demonstrates commitment
and enthusiasm for role.
Willing to challenge
unacceptable behaviour or
behaviour
that threatens patient safety,
when appropriate. Takes
responsibility for own actions.
1. Is punctual
2. Takes responsibility for own actions/work
3. Owns up to mistakes
4. Takes responsibility for own health and well-being
5. Demonstrates commitment to and enthusiasm/motivation
for role
6. Understands/is aware of the responsibility of the role of
being a doctor
7. Is reliable
8. Displays honesty towards others (colleagues and patients)
9. Trustworthy
10. Identifies/challenges unacceptable/unsafe
behaviour/situations when appropriate
(colleague/organisational issues)
11. Challenges others’ knowledge where appropriate
12. Understands/demonstrates awareness of ethical issues,
including confidentiality

2. Coping with Pressure 1. Remains calm and in control of situations

Capability to work under
pressure and remain resilient.
Demonstrates ability to adapt
to changing circumstances and
manage uncertainty. Remains
calm when faced with
confrontation. Develops and
employs appropriate coping
strategies and demonstrates
judgement under pressure.
2. Manages uncertainty/ambiguity
3. Effectively deals with outcomes of mistakes/decisions
4. Exhibits flexibility/adaptability when dealing with
changing circumstance or issues
5. Employs effective coping mechanisms for dealing with
stress/emotions
6. Demonstrates good judgement under pressure
7. Does not give up easily
8. Deals appropriately with confrontational/difficult
situations (colleagues/patients)
9. Seeks support when faced with stress/pressure

13
3. Effective Communication General
Actively and clearly engages
patients 1. Listens effectively
and colleagues in equal/open 2. Ensures surroundings are appropriate when
dialogue. Demonstrates active communicating
listening. Communicates 3. Understands/responds to non-verbal cues
verbal and written information 4. Uses non-verbal communication effectively
concisely and with clarity.
Adapts style of
communication ac- cording to
individual needs and context.
Able to negotiate with
colleagues and patients
effectively.
With patients

1. Uses language that is understood by patients/relatives

and free from medical jargon
2. Demonstrates sensitive use of language
3. Communicates information to patients clearly and
concisely
4. Adjusts style of communication according to patient’s/
relative’s needs
5. Adjusts how much information to provide according to
patient’s/relative’s needs
6. Provides information to patients and keeps them updated
7. Readily answers patient’s and relative’s questions
8. Ensures he/she has all the relevant information before
communicating to patients/colleagues
9. Asks questions/seeks clarification to gain more
information/ understanding about the patient
10. Finds out patient’s/relative’s level of knowledge/
understanding
11. Allows patients/relatives to ask questions and uses silence
effectively
12. Checks patient’s/relative’s understanding
13. Summarises information / reflects back to patients to
clarify their own understanding

With colleagues

1. Asks questions of colleagues to gain more information

2. Provides/summarises information accurately and
concisely to colleagues
3. Provides only relevant information to colleagues
4. Keeps colleagues informed/updated (about patients and
about where they will be)

14
 5. Is able to negotiate/ use diplomacy
6. Knows exactly what colleagues are asking for and why
7. Is assertive where necessary
8. Adapts style of communication according to need and
situation
9. Clarifies information to check their own understanding

Written

1. Displays high standards of written communication

2. Uses concise and clear written communication
3. Has legible handwriting

The Duties of a doctor registered with the GMC

Good medical practice describes what it means to be a good doctor.

It says that as a good doctor you will:

 make the care of your patient your first concern

 be competent and keep your professional knowledge and skills up to date
 take prompt action if you think patient safety is being compromised
 establish and maintain good partnerships with your patients and colleagues

15
  maintain trust in you and the profession by being open, honest and acting with
integrity.

This guidance is split into four sections which describe the professional values and
behaviours we expect from any doctor registered with us. We expect you to use your
professional judgement and expertise to apply the principles in this guidance to the various
situations you face.

Patients must be able to trust doctors with their lives and health. To justify that trust you
must show respect for human life and make sure your practice meets the standards
expected of you in four domains.

Knowledge, skills and performance

 Make the care of your patient your first concern.
 Provide a good standard of practice and care.
o Keep your professional knowledge and skills up to date.
o Recognise and work within the limits of your competence.

Safety and quality

 Take prompt action if you think that patient safety, dignity or comfort is being
compromised.
 Protect and promote the health of patients and the public.

Communication, partnership and teamwork

 Treat patients as individuals and respect their dignity.
o Treat patients politely and considerately.
o Respect patients' right to confidentiality.
 Work in partnership with patients.
o Listen to, and respond to, their concerns and preferences.
o Give patients the information they want or need in a way they can
understand.
o Respect patients' right to reach decisions with you about their treatment and
care.
o Support patients in caring for themselves to improve and maintain their
health.
 Work with colleagues in the ways that best serve patients' interests.

Maintaining trust
 Be honest and open and act with integrity.
 Never discriminate unfairly against patients or colleagues.
 Never abuse your patients' trust in you or the public's trust in the profession.
 You are personally accountable for your professional practice and must always be
prepared to justify your decisions and actions...

Professionalism in action

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1 Patients need good doctors. Good doctors make the care of their patients their first
concern: they are competent, keep their knowledge and skills up to date, establish and
maintain good relationships with patients and colleagues,1 are honest and trustworthy, and
act with integrity and within the law.

2 Good doctors work in partnership with patients and respect their rights to privacy and
dignity. They treat each patient as an individual. They do their best to make sure all patients
receive good care and treatment that will support them to live as well as possible, whatever
their illness or disability.

3 Good medical practice describes what is expected of all doctors registered with the
General Medical Council (GMC). It is your responsibility to be familiar with Good medical
practice and the explanatory guidance2 which supports it, and to follow the guidance they
contain.

4 You must use your judgement in applying the principles to the various situations you will
face as a doctor, whether or not you hold a licence to practise, whatever field of medicine
you work in, and whether or not you routinely see patients. You must be prepared to
explain and justify your decisions and actions.

5 In Good medical practice, we use the terms ‘you must’ and ‘you should’ in the following
ways.

 ‘You must’ is used for an overriding duty or principle.

 'You should’ is used when we are providing an explanation of how you will meet the
overriding duty.
 'You should’ is also used where the duty or principle will not apply in all situations or
circumstances, or where there are factors outside your control that affect whether
or how you can follow the guidance.

6 To maintain your licence to practise, you must demonstrate, through the revalidation
process, that you work in line with the principles and values set out in this guidance. Serious
or persistent failure to follow this guidance will put your registration at risk.

Domain 1: Knowledge, skills & performance

Develop and maintain your professional performance

7 You must be competent in all aspects of your work, including management, research and
teaching.3 4 5

8 You must keep your professional knowledge and skills up to date.

17
9 You must regularly take part in activities that maintain and develop your competence and
performance.6

10 You should be willing to find and take part in structured support opportunities offered by
your employer or contracting body (for example, mentoring). You should do this when you
join an organisation and whenever your role changes significantly throughout your career.

11 You must be familiar with guidelines and developments that affect your work.

12 You must keep up to date with, and follow, the law, our guidance and other regulations
relevant to your work.

13 You must take steps to monitor and improve the quality of your work.

Apply knowledge and experience to practice

14 You must recognise and work within the limits of your competence.
14.1 You must have the necessary knowledge of the English language to provide a good
standard of practice and care in the UK.7

15 You must provide a good standard of practice and care. If you assess, diagnose or treat
patients, you must:

a. adequately assess the patient’s conditions, taking account of their history (including
the symptoms and psychological, spiritual, social and cultural factors), their views
and values; where necessary, examine the patient
b. promptly provide or arrange suitable advice, investigations or treatment where
necessary
c. refer a patient to another practitioner when this serves the patient’s needs.8

16 In providing clinical care you must:

a. prescribe drugs or treatment, including repeat prescriptions, only when you have
adequate knowledge of the patient’s health and are satisfied that the drugs or
treatment serve the patient’s needs9
b. provide effective treatments based on the best available evidence
c. take all possible steps to alleviate pain and distress whether or not a cure may be
possible10
d. consult colleagues where appropriate
e. respect the patient’s right to seek a second opinion
f. check that the care or treatment you provide for each patient is compatible with any
other treatments the patient is receiving, including (where possible) self-prescribed
over-the-counter medications
g. wherever possible, avoid providing medical care to yourself or anyone with whom
you have a close personal relationship.9

18
17 You must be satisfied that you have consent or other valid authority before you carry out
any examination or investigation, provide treatment or involve patients or volunteers in
teaching or research.4 11 12

18 You must make good use of the resources available to you.3

Record your work clearly, accurately and legibly

19 Documents you make (including clinical records) to formally record your work must be
clear, accurate and legible. You should make records at the same time as the events you are
recording or as soon as possible afterwards.

20 You must keep records that contain personal information about patients, colleagues or
others securely, and in line with any data protection law requirements.14

21 Clinical records should include:

a. relevant clinical findings
b. the decisions made and actions agreed, and who is making the decisions and
agreeing the actions
c. the information given to patients
d. any drugs prescribed or other investigation or treatment
e. who is making the record and when.

Domain 2: Safety & Quality

Contribute to and comply with systems to protect patients

22 You must take part in systems of quality assurance and quality improvement to promote
patient safety. This includes:
a. taking part in regular reviews and audits of your own work and that of your team,
responding constructively to the outcomes, taking steps to address any problems
and carrying out further training where necessary
b. regularly reflecting on your standards of practice and the care you provide
c. reviewing patient feedback where it is available.

23 To help keep patients safe you must:

a. contribute to confidential inquiries
b. contribute to adverse event recognition
c. report adverse incidents involving medical devices that put or have the potential to
put the safety of a patient, or another person, at risk
d. report suspected adverse drug reactions
e. respond to requests from organisations monitoring public health. When providing
information for these purposes you should still respect patients’ confidentiality. 14

Respond to risks to safety

24 You must promote and encourage a culture that allows all staff to raise concerns openly
and safely.3 15

19
25 You must take prompt action if you think that patient safety, dignity or comfort is or may
be seriously compromised.
a. If a patient is not receiving basic care to meet their needs, you must immediately tell
someone who is in a position to act straight away.
b. If patients are at risk because of inadequate premises, equipment13 or other
resources, policies or systems, you should put the matter right if that is possible. You
must raise your concern in line with our guidance14 and your workplace policy. You
should also make a record of the steps you have taken.
c. If you have concerns that a colleague may not be fit to practise and may be putting
patients at risk, you must ask for advice from a colleague, your defence body or us. If
you are still concerned you must report this, in line with our guidance and your
workplace policy, and make a record of the steps you have taken.14 16

26 You must offer help if emergencies arise in clinical settings or in the community, taking
account of your own safety, your competence and the availability of other options for care.

27 Whether or not you have vulnerable17 adults or children and young people as patients,
you should consider their needs and welfare and offer them help if you think their rights
have been abused or denied.18 19

Risks posed by your health

28 If you know or suspect that you have a serious condition that you could pass on to
patients, or if your judgement or performance could be affected by a condition or its
treatment, you must consult a suitably qualified colleague. You must follow their advice
about any changes to your practice they consider necessary. You must not rely on your own
assessment of the risk to patients.

29 You should be immunised against common serious communicable diseases (unless

otherwise contraindicated).

30 You should be registered with a general practitioner outside your family.

Domain 3: Communication, partnership & teamwork

Communicate effectively
31 You must listen to patients, take account of their views, and respond honestly to their
questions.

32 You must give patients20 the information they want or need to know in a way they can
understand. You should make sure that arrangements are made, wherever possible, to
meet patients’ language and communication needs.21

33 You must be considerate to those close to the patient and be sensitive and responsive in
giving them information and support.

20
34 When you are on duty you must be readily accessible to patients and colleagues seeking
information, advice or support.

Working collaboratively with colleagues

35 You must work collaboratively with colleagues, respecting their skills and contributions. 3

36 You must treat colleagues fairly and with respect.

37 You must be aware of how your behaviour may influence others within and outside the
team.

38 Patient safety may be affected if there is not enough medical cover. So you must take up
any post you have formally accepted, and work your contractual notice period before
leaving a job, unless the employer has reasonable time to make other arrangements.

Teaching, training, supporting and assessing

39 You should be prepared to contribute to teaching and training doctors and students.

40 You must make sure that all staff you manage have appropriate supervision.

41 You must be honest and objective when writing references, and when appraising or
assessing the performance of colleagues, including locums and students. References must
include all information relevant to your colleagues’ competence, performance and
conduct.22

42 You should be willing to take on a mentoring role for more junior doctors and other
healthcare professionals.3

43 You must support colleagues who have problems with their performance or health. But
you must put patient safety first at all times.3

Continuity and coordination of care

44 You must contribute to the safe transfer of patients between healthcare providers and
between health and social care providers. This means you must:
a. share all relevant information with colleagues involved in your patients’ care within
and outside the team, including when you hand over care as you go off duty, and
when you delegate care or refer patients to other health or social care providers 8
b. check, where practical, that a named clinician or team has taken over responsibility
when your role in providing a patient’s care has ended. This may be particularly
important for patients with impaired capacity or who are vulnerable for other
reasons.

45 When you do not provide your patients’ care yourself, for example when you are off
duty, or you delegate the care of a patient to a colleague, you must be satisfied that the

21
person providing care has the appropriate qualifications, skills and experience to provide
safe care for the patient.8

Establish and maintain partnerships with patients

46 You must be polite and considerate.

47 You must treat patients as individuals and respect their dignity and privacy. 16

48 You must treat patients fairly and with respect whatever their life choices and beliefs.

49 You must work in partnership with patients, sharing with them the information they will
need to make decisions about their care,21 including:
a. their condition, its likely progression and the options for treatment, including
associated risks and uncertainties
b. the progress of their care, and your role and responsibilities in the team
c. who is responsible for each aspect of patient care, and how information is shared
within teams and among those who will be providing their care
d. any other information patients need if they are asked to agree to be involved in
teaching or research.12

50 You must treat information about patients as confidential. This includes after a patient
has died.14

51 You must support patients in caring for themselves to empower them to improve and
maintain their health. This may, for example, include:
a. advising patients on the effects of their life choices and lifestyle on their health and
well-being
b. supporting patients to make lifestyle changes where appropriate.

52 You must explain to patients if you have a conscientious objection to a particular

procedure. You must tell them about their right to see another doctor and make sure they
have enough information to exercise that right. In providing this information you must not
imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical
for a patient to arrange to see another doctor, you must make sure that arrangements are
made for another suitably qualified colleague to take over your role.23

Domain 4: Maintaining trust

Show respect for patients

53 You must not use your professional position to pursue a sexual or improper emotional
relationship with a patient or someone close to them.16

54 You must not express your personal beliefs (including political, religious and moral
beliefs) to patients in ways that exploit their vulnerability or are likely to cause them
distress.23

22
55 You must be open and honest with patients if things go wrong. If a patient under your
care has suffered harm or distress, you should:
a. put matters right (if that is possible)
b. offer an apology
c. explain fully and promptly what has happened and the likely short-term and long-
term effects.

Treat patients and colleagues fairly and without discrimination

56 You must give priority to patients on the basis of their clinical need if these decisions are
within your power. If inadequate resources, policies or systems prevent you from doing this,
and patient safety, dignity or comfort may be seriously compromised, you must follow the
guidance in paragraph 25b.

57 The investigations or treatment you provide or arrange must be based on the assessment
you and your patient make of their needs and priorities, and on your clinical judgement
about the likely effectiveness of the treatment options. You must not refuse or delay
treatment because you believe that a patient’s actions or lifestyle have contributed to their
condition.

58 You must not deny treatment to patients because their medical condition may put you at
risk. If a patient poses a risk to your health or safety, you should take all available steps to
minimise the risk before providing treatment or making other suitable alternative
arrangements for providing treatment.

59 You must not unfairly discriminate against patients or colleagues by allowing your
personal views24 to affect your professional relationships or the treatment you provide or
arrange. You should challenge colleagues if their behaviour does not comply with this
guidance, and follow the guidance in paragraph 25c if the behaviour amounts to abuse or
denial of a patient’s or colleague’s rights.

60 You must consider and respond to the needs of disabled patients and should make
reasonable adjustments25 to your practice so they can receive care to meet their needs.

61 You must respond promptly, fully and honestly to complaints and apologise when
appropriate. You must not allow a patient’s complaint to adversely affect the care or
treatment you provide or arrange.

62 You should end a professional relationship with a patient only when the breakdown of
trust between you and the patient means you cannot provide good clinical care to the
patient.26

63 You must make sure you have adequate insurance or indemnity cover so that your
patients will not be disadvantaged if they make a claim about the clinical care you have
provided in the UK.

23
64 If someone you have contact with in your professional role asks for your registered name
and/or GMC reference number, you must give this information to them.

Act with honesty and integrity

Honesty

65 You must make sure that your conduct justifies your patients’ trust in you and the
public’s trust in the profession.

66 You must always be honest about your experience, qualifications and current role.

67 You must act with honesty and integrity when designing, organising or carrying out
research, and follow national research governance guidelines and our guidance. 4

Communicating information

68 You must be honest and trustworthy in all your communication with patients and
colleagues. This means you must make clear the limits of your knowledge and make
reasonable checks to make sure any information you give is accurate.

69 When communicating publicly, including speaking to or writing in the media, you must
maintain patient confidentiality. You should remember when using social media that
communications intended for friends or family may become more widely available.14, 27

70 When advertising your services, you must make sure the information you publish is
factual and can be checked, and does not exploit patients’ vulnerability or lack of medical
knowledge.

71 You must be honest and trustworthy when writing reports, and when completing or
signing forms, reports and other documents.22 You must make sure that any documents you
write or sign are not false or misleading.
a. You must take reasonable steps to check the information is correct.
b. You must not deliberately leave out relevant information.

Openness and legal or disciplinary proceedings

72 You must be honest and trustworthy when giving evidence to courts or tribunals.28 You
must make sure that any evidence you give or documents you write or sign are not false or
misleading.
a. You must take reasonable steps to check the information.
b. You must not deliberately leave out relevant information.

73 You must cooperate with formal inquiries and complaints procedures and must offer all
relevant information while following the guidance in Confidentiality.

24
74 You must make clear the limits of your competence and knowledge when giving evidence
or acting as a witness.28

75 You must tell us without delay if, anywhere in the world:

a. you have accepted a caution from the police or been criticised by an official inquiry
b. you have been charged with or found guilty of a criminal offence
c. another professional body has made a finding against your registration as a result of
fitness to practise procedures.29

76 If you are suspended by an organisation from a medical post, or have restrictions placed
on your practice, you must, without delay, inform any other organisations you carry out
medical work for and any patients you see independently.

Honesty in financial dealings

77 You must be honest in financial and commercial dealings with patients, employers,
insurers and other organisations or individuals.30

78 You must not allow any interests you have to affect the way you prescribe for, treat,
refer or commission services for patients.

79 If you are faced with a conflict of interest, you must be open about the conflict, declaring
your interest formally, and you should be prepared to exclude yourself from decision
making.

80 You must not ask for or accept – from patients, colleagues or others – any inducement,
gift or hospitality that may affect or be seen to affect the way you prescribe for, treat or
refer patients or commission services for patients. You must not offer these inducements.
Good Medical Practice in Action

Scenario 1
Brian – 48 yo CEO
 Mistakenly prescribed penicillin which he’d had an allergic reaction to in the past (by
another doctor)
 Brian - “Not improving, feel just as bad and have this awful rash”
 You – “Dr H shouldn’t really have prescribed you penicillin. Your records show you’ve
had a bad reaction to it in the past”
 Brian – Mad as fuck, That’s just incompetence, this place is useless
 You
o Option 1 – Insist he calms down
o Option 2 – Offer an appointment with Dr H when he comes back from his
leave so he can explain and apologise
o Option 3 – Apologise on Dr H’s behalf, explain what is likely to happen now in
terms of his symptoms and the best treatment

Option 3 – best reflects GMC guidance  prompt apology & explanation

 NHS Litigation Authority confirms that an apology is NOT an admission of liability

25
If consultation turns aggressive/violent or threatening – NHS non-physical assault policy –
we are justified in ending the consultation

References
You must be open and honest with patients if things go wrong. If a patient under your care
has suffered harm or distress, you must:
a. Put matters right (if that is possible)
b. Offer an apology
c. Explain fully and promptly what has happened and the likely short-term and long-term
effects. (Good Medical Practice paragraph 55)

Scenario 2
Brian comes with some palpitations, wants a referral to a consultant, unaware that there is
a GP in the practice with a special interest in cardio, makes snide comments about Dr H

Option 1 - Tell him about the GP with a special interest in cardio at the practice who could
carry out the appropriate tests
Option 2 - Refer Brian for further Ix by a consultant although there is a waiting list
Option 3 - Say you are no longer willing to treat Brian because of his attitude towards Dr H
and the trouble his complaint is causing the practice

Correct – option 1
 Ignore his snide comments about Dr H
 In his best interest to have his investigations asap – This option is quicker than the
consultant referral & investigation is the same
Doctors must not allow a patient’s complaint to adversely affect the treatment they
provide or arrange

References
You must respond promptly, fully and honestly to complaints and offer an apology when
appropriate.
You should end a professional relationship with a patient only when the breakdown of trust
between you and the patient means you cannot provide good clinical care to the
patient.10(Good Medical Practice paragraphs 61 and 62)

Scenario 3
Dr H continues to underperform since his return to work
Receptionist Jenny comes to see you, concerned that pts may be at risk
 He looks sleepy, maybe smells of alcohol, Mark saw him coming out of the White
Hart
 You – he had a lot to deal with, I suggested he takes more time off but he says work
is the only thing that keeps him going (wife died)
 Jenny – what happens if he makes another mistake?

Option 1 – Report Dr H to the GMC

26
Option 2 – Speak to Dr H and try to persuade him to have more time off
Option 3 – Consult the GMC without giving Dr H’s name, and call the local Primary Care
Trust (PCT)

Correct – option 3
Doctors, their colleagues, patients and employers can contact the GMC to talk through a
situation confidentially to help them come to a decision. Those working with the doctor in
question will usually be in a better position to judge the risk to patient safety. The British
Medical Association and medical defence bodies (like the MDU and MPS) also give
confidential ethical advice to their members.

See what the doctor did

Dr Singh decided to call the GMC for confidential advice, and to help him come to a view
about the risk to patients. He went in to see Dr Hargreaves immediately after speaking to
the GMC, told him he had decided to inform the Primary Care Trust (PCT) and asked him to
stop seeing patients immediately. Dr Singh was very supportive and persuaded Dr
Hargreaves to go to his GP and to make an appointment with a counsellor.

References
You must support colleagues who have problems with their performance or health. But you
must put patient safety first at all times.14
(Good Medical Practice paragraph 43)

...act immediately to put matters right...

If things go wrong with a patient's care doctors must be open and honest and prepared to
apologise themselves to the patient (or their relatives) whether or not they were personally
responsible for the incident. Guidance from the NHS Litigation Authority confirms that an
apology is not an admission of liability - which is a concern that some doctors have about
apologising. GMC guidance (in Good Medical Practice) states that an apology should be
offered, but it is more important that the doctor explains fully and promptly what's
happened, and what are likely to be the effects in both the short and long term.
That's why Dr Singh chooses to empathise with with Brian's angry reaction rather than
refusing to continue with the consultation until Brian calms down. Having said that, there
are of course limits on the behaviour doctors are expected to tolerate from their patients.
The NHS and other employers have policies for dealing with aggressive and violent patients,
and when it may be appropriate to end the professional relationship.
Patients must not be removed from a doctor's list simply because they have made a
complaint about them: they must feel able to complain about their treatment without fear
of being left without access to healthcare.

...a prompt, open, honest and constructive response...

If a patient makes a complaint about a doctor, that doctor must be careful not to allow the
complaint to prejudice the treatment they provide or arrange. If Dr Singh feels that the
investigation should be carried out as soon as possible, if the GP with a Special Interest
referral would be quicker than the consultant referral, and if the test is the same, Dr Singh
would not be acting in Brian's best interests if he referred him to the consultant, if Brian
wasn't aware of the better option, even if this is what Brian requested.

27
...protect patients from risk of harm...
If a doctor suspects that a colleague may not be fit to practise, they must take steps
immediately to ensure that patients are protected. This will usually mean informing the
doctor's employer and - for more serious cases - their regulator, the GMC. It may not be
necessary to inform the GMC about a doctor if the complaint can be handled appropriately
locally. The doctor's employers are in a better position to act quickly to assess a situation
and ensure patient protection than a national body like the GMC. However, if there is a
possibility that the doctor's right to practise may need to be restricted or removed, the GMC
must be informed as well.
Our supplementary guidance on Raising and Acting on Concerns deals in more detail with
what steps to take when doctors have concerns that one of their colleagues may be putting
patients at risk. This duty to raise a concern also extends to resources, equipment and
policies that may be putting patients at risk
In this case study, there may be an immediate risk to Dr Hargreaves' patients, particularly if
he's been drinking, so waiting until surgery is over will not protect those patients he will see
today.
Good Medical Practice also makes it clear that colleagues who have problems with their
performance, conduct or health must be supported, even if it was the doctor who raised the
alarm in the first instance. In this case, giving Dr Hargreaves more time off without any
additional support, could make the situation worse, and make him feel more isolated.
Doctors - and patients and employers - can contact the GMC to talk through a situation
confidentially, to help them come to a decision about whether or not to refer a doctor for
further investigation of concerns. Those working with the doctor in question - i.e. those
making the call - will usually be in the best position to judge the risk to patient safety, but it
can help to talk through the circumstances with someone else. The British Medical
Association and medical defence bodies (like the MDU, MPS and MDDUS) also give
confidential ethical advice to their members.

28
Sexual behaviour and your dury to report colleagues

In Good medical practice1 we say:

25c. If you have concerns that a colleague may not be fit to practise and may be putting
patients at risk, you must ask for advice from a colleague, your defence body or us. If you
are still concerned you must report this, in line with our guidance and your workplace
policy, and make a record of the steps you have taken.

53. You must not use your professional position to pursue a sexual or improper emotional
relationship with a patient or someone close to them.

2 In this guidance, we explain how doctors can put these principles into practice. Serious or
persistent failure to follow this guidance will put your registration at risk.

3 To maintain the trust of patients and the public, you must never make a sexual advance
towards a patient or display sexual behaviour. Sexual behaviour – for example, making
inappropriate sexual comments – does not necessarily involve touching the patient.

4 If a patient tells you about a breach of sexual boundaries, or you have other reasons to
believe that a colleague2 has, or may have, displayed sexual behaviour towards a patient,
you must promptly report your concerns3 to a person or organisation able to investigate the
allegation. If you suspect a doctor has committed a sexual assault or other criminal activity,
you should make sure it is reported to the police.

5 You must offer support to any of your patients affected by a colleague’s breach of sexual
boundaries.

6 You should respect patient confidentiality4 when reporting your concerns. But, the safety
of patients must come first at all times. If you are satisfied that it is necessary to identify the
patient, you should explain to the patient why disclosure is necessary. You should seek the
patient’s consent to disclose information, unless it is not appropriate or practical to do
so.5 If consent to disclosure is refused but you judge disclosure is in the public interest, you
must tell the patient of your intention to disclose the information. In all cases, you should
only disclose relevant information.

29
Ethical & Legal duties of confidentiality

Main principles

The advice in this guidance is underpinned by the following eight principles. 3

a. Use the minimum necessary personal information. Use anonymised information if it

is practicable to do so and if it will serve the purpose.
b. Manage and protect information. Make sure any personal information you hold or
control is effectively protected at all times against improper access, disclosure or
loss.
c. Be aware of your responsibilities. Develop and maintain an understanding of
information governance that is appropriate to your role.
d. Comply with the law. Be satisfied that you are handling personal information
lawfully.
e. Share relevant information for direct care in line with the principles in this guidance
unless the patient has objected.
f. Ask for explicit consent to disclose identifiable information about patients for
purposes other than their care or local clinical audit, unless the disclosure is required
by law or can be justified in the public interest.
g. Tell patients about disclosures of personal information you make that they would
not reasonably expect, or check they have received information about such
disclosures, unless that is not practicable or would undermine the purpose of the
disclosure. Keep a record of your decisions to disclose, or not to disclose,
information.
h. Support patients to access their information. Respect, and help patients exercise,
their legal rights to be informed about how their information will be used and to
have access to, or copies of, their health records.

When you can disclose personal information

9 Confidentiality is an important ethical and legal duty but it is not absolute. You may
disclose personal information without breaching duties of confidentiality when any of the
following circumstances applies.

a. The patient consents, whether implicitly or explicitly for the sake of their own care or
for local clinical audit, or explicitly for other purposes (see paragraphs 13 - 15).
b. The patient has given their explicit consent to disclosure for other purposes
(see paragraphs 13 - 15 ).
c. The disclosure is of overall benefit4 to a patient who lacks the capacity to consent
(see paragraphs 41 - 49).

30
 d. The disclosure is required by law (see paragraphs 17 - 19), or the disclosure is
permitted or has been approved under a statutory process that sets aside the
common law duty of confidentiality (see paragraphs 20 - 21).
e. The disclosure can be justified in the public interest (see paragraphs 22 - 23).

10 When disclosing information about a patient you must:

a. use anonymised information if it is practicable to do so and if it will serve the

purpose
b. be satisfied the patient:
i. has ready access to information explaining how their personal information
will be used for their own care or local clinical audit, and that they have the
right to object
ii. has not objected
c. get the patient’s explicit consent if identifiable information is to be disclosed for
purposes other than their own care or local clinical audit, unless the disclosure is
required by law or can be justified in the public interest
d. keep disclosures to the minimum necessary for the purpose
e. follow all relevant legal requirements, including the common law and data
protection law.5

11 When you are satisfied that information should be disclosed, you should act promptly to
disclose all relevant information. You should keep a record of your decision and actions.

12 You should tell patients about disclosures you make that they would not reasonably
expect, or check they have received information about such disclosures, unless that is not
practicable or would undermine the purpose of the disclosure – for example, by prejudicing
the prevention, detection or prosecution of serious crime.

Disclosing information with a patient's consent

13 Asking for a patient’s consent to disclose information shows respect, and is part of good
communication between doctors and patients. Under the common law duty of
confidentiality, consent may be explicit or implied.6

a. Explicit (also known as express) consent is given when a patient actively agrees,
either orally or in writing, to the use or disclosure of information.
b. Implied consent refers to circumstances in which it would be reasonable to infer that
the patient agrees to the use of the information, even though this has not been
directly expressed.

14 You may disclose information on the basis of implied consent for direct care when the
conditions in paragraphs 28 and 29 are met, and for local clinical audit when the conditions
in paragraph 96 are met. In other cases, you should ask for explicit consent to disclose
personal information unless it is not appropriate or practicable to do so.

For example, this might be because:

31
 a. the disclosure is required by law (see paragraphs 17 - 19)
b. you are satisfied that informed consent has already been obtained by a suitable
person7
c. the patient does not have capacity to make the decision. In such a case, you should
follow the guidance on disclosures about patients who lack capacity to consent
(see paragraphs 41 - 49)
d. you have reason to believe that seeking consent would put you or others at risk of
serious harm
e. seeking consent would be likely to undermine the purpose of the disclosure, for
example by prejudicing the prevention, detection or prosecution of a serious crime
f. action must be taken quickly, for example in the detection or control of outbreaks of
some communicable diseases where there is insufficient time to contact the patient
g. seeking consent is not feasible given the number or age of records, or the likely
traceability of patients.
h. you have already decided to disclose information in the public interest
(see paragraphs 63 - 70).

15 If you disclose personal information without consent, you must be satisfied that there is
a legal basis for breaching confidentiality (see paragraph 9). You must also be satisfied that
the other relevant requirements for disclosing information are met (see paragraph 10).

Disclosing information when a patient lacks the capacity to consent

16 You may disclose relevant personal information about a patient who lacks the capacity to
consent if it is of overall benefit to the patient. You can find more guidance on this
in paragraphs 41 - 49.

Disclosures required or permitted by law

17 You must disclose information if it is required by statute, or if you are ordered to do so

by a judge or presiding officer of a court (see paragraphs 87 - 94).

18 You should satisfy yourself that the disclosure is required by law and you should only
disclose information that is relevant to the request. Wherever practicable, you should tell
patients about such disclosures, unless that would undermine the purpose, for example by
prejudicing the prevention, detection or prosecution of serious crime.

19 Laws and regulations sometimes permit, but do not require, the disclosure of personal
information.8 If a disclosure is permitted but not required by law, you must be satisfied that
there is a legal basis for breaching confidentiality (see paragraph 9). You must also be
satisfied that the other relevant requirements for disclosing information are met
(see paragraph 10).

Disclosures approved under a legal process

32
20 You may disclose personal information without consent if the disclosure is permitted or
has been approved under section 251 of the National Health Service Act 2006 (which applies
in England and Wales) or the Health and Social Care (Control of Data Processing) Act
(Northern Ireland) 2016. These pieces of law allow the common law duty of confidentiality
to be set aside for defined purposes where it is not possible to use anonymised information
and where seeking consent is not practicable. There is no comparable legal framework in
Scotland.

21 If you know that a patient has objected to information being disclosed for purposes other
than their own care, you should not usually disclose the information unless it is required
under the regulations. You can find more guidance on disclosures with specific statutory
support in paragraphs 103 - 105.

Disclosures in the public interest

22 Confidential medical care is recognised in law as being in the public interest. The fact that
people are encouraged to seek advice and treatment benefits society as a whole as well as
the individual. But there can be a public interest in disclosing information if the benefits to
an individual or society outweigh both the public and the patient’s interest in keeping the
information confidential. For example, disclosure may be justified to protect individuals or
society from risks of serious harm, such as from serious communicable diseases or serious
crime. You can find guidance on disclosing information in the public interest to prevent
death or serious harm in paragraphs 63 - 70.

23 There may also be circumstances in which disclosing personal information without

consent is justified in the public interest for important public benefits, other than to prevent
death or serious harm, if there is no reasonably practicable alternative to using personal
information. The circumstances in which the public interest would justify such disclosures
are uncertain, however, so you should seek the advice of a Caldicott or data guardian or a
legal adviser who is not directly connected with the use for which the disclosure is being
considered before making the disclosure. You can find further guidance in paragraphs 106 -
112.

Disclosures prohibited by law

24 Health professionals are required by certain laws to restrict the disclosure of some types
of information. You can find examples of disclosures prohibited by law in the legal annex.

Data protection law

25 This guidance focuses on doctors’ ethical and legal duties of confidentiality. But the
processing of personal data must also satisfy the requirements of data protection law,
which imposes various duties on data controllers. Individual doctors can be data controllers
in their own right (for instance if they are partners in general practice or hold data about
patients whom they treat privately), but in many cases the data controller will be the

33
doctor’s employer. This guidance aims to be consistent with data protection law, but it is
not guidance on the law. You can however find an overview of data protection law and its
relationship with the common law duty of confidence in the legal annex.

Using & disclosing patient information for direct care

Sharing information for direct care

26 Appropriate information sharing is an essential part of the provision of safe and effective
care. Patients may be put at risk if those who provide their care do not have access to
relevant, accurate and up-to-date information about them.9 Multidisciplinary and multi-
agency teamwork is also placing increasing emphasis on integrated care and partnership
working, and information sharing is central to this, but information must be shared within
the framework provided by law and ethics.

Implied consent and sharing information for direct care

27 Most patients understand and expect that relevant information must be shared within
the direct care team to provide their care.19 You should share relevant information with
those who provide or support direct care to a patient, unless the patient has objected
(see paragraphs 30 and 31).11
28

The usual basis for sharing information for a patient’s own care is the patient’s consent,
whether that is explicit or implied (see paragraph 13 for definitions). You may rely on
implied consent to access relevant information about the patient or to share it with those
who provide (or support the provision of) direct care to the patient if all of the following are
met.

a. You are accessing the information to provide or support the individual patient’s
direct care, or are satisfied that the person you are sharing the information with is
accessing or receiving it for this purpose.
b. Information is readily available to patients, explaining how their information will be
used and that they have the right to object. This can be provided in leaflets and
posters, on websites, and face to face. It should be tailored to patients’ identified
communication requirements as far as practicable.
c. You have no reason to believe the patient has objected.
d. You are satisfied that anyone you disclose personal information to understands that
you are giving it to them in confidence, which they must respect.

34
29 If you suspect a patient would be surprised to learn about how you are accessing or
disclosing their personal information, you should ask for explicit consent unless it is not
practicable to do so (see paragraph 14). For example, a patient may not expect you to have
access to information from another healthcare provider or agency on a shared record.

Patient objections to sharing information for their own care

30 If a patient objects to particular personal information being shared for their own care,
you should not disclose the information unless it would be justified in the public
interest,12 or is of overall benefit to a patient who lacks the capacity to make the decision.
You can find further guidance on disclosures of information about adults who lack capacity
to consent in paragraphs 41 - 49.

31 You should explain to the patient the potential consequences of a decision not to allow
personal information to be shared with others who are providing their care. You should also
consider with the patient whether any compromise can be reached. If, after discussion, a
patient who has capacity to make the decision still objects to the disclosure of personal
information that you are convinced is essential to provide safe care, you should explain that
you cannot refer them or otherwise arrange for their treatment without also disclosing that
information.
If a patient cannot be informed

32 Circumstances may arise in which a patient cannot be informed about the disclosure of
personal information, for example in a medical emergency. In such cases, you should pass
relevant information promptly to those providing the patient’s care.

33 If the patient regains the capacity to understand, you should inform them how their
personal information was disclosed if it was in a way they would not reasonably expect.

Sharing information with those close to the patient

34 You must be considerate to those close to the patient and be sensitive and responsive in
giving them information and support, while respecting the patient’s right to confidentiality.
Establishing what the patient wants

35 The people close to a patient can play a significant role in supporting, or caring for, the
patient and they may want or need information about the patient’s diagnosis, treatment or
care. Early discussions about the patient’s wishes can help to avoid disclosures they might
object to.

Such discussions can also help avoid misunderstandings with, or causing offence or distress
to, anyone the patient would want information to be shared with.

35
36 You should establish with the patient what information they want you to share, with
whom, and in what circumstances. This will be particularly important if the patient has
fluctuating or diminished capacity or is likely to lose capacity, even temporarily. You should
document the patient’s wishes in their records.
Abiding by the patient's wishes

37 If a patient who has capacity to make the decision refuses permission for information to
be shared with a particular person or group of people, it may be appropriate to encourage
the patient to reconsider that decision if sharing the information may be beneficial to the
patient’s care and support. You must, however, abide by the patient’s wishes, unless
disclosure would be justified in the public interest (see paragraphs 63 - 70).

38 If a patient lacks capacity to make the decision, it is reasonable to assume the patient
would want those closest to them to be kept informed of their general condition and
prognosis, unless they indicate (or have previously indicated) otherwise. You can find
detailed advice on considering disclosures about patients who lack capacity to consent
in paragraphs 41 - 49.
Listening to those close to the patient

39 In most cases, discussions with those close to the patient will take place with the
patient’s knowledge and consent. But if someone close to the patient wants to discuss their
concerns about the patient’s health without involving the patient, you should not refuse to
listen to their views or concerns on the grounds of confidentiality. The information they give
you might be helpful in your care of the patient.

40 You should, however, consider whether your patient would consider you listening to the
views or concerns of others to be a breach of trust, particularly if they have asked you not to
listen to specific people. You should also make clear that, while it is not a breach of
confidentiality to listen to their concerns, you might need to tell the patient about
information you have received from others – for example, if it has influenced your
assessment and treatment of the patient.13 You should also take care not to disclose
personal information unintentionally – for example, by confirming or denying the person’s
perceptions about the patient’s health.

Disclosures about patients who lack capacity to consent

41 You must work on the presumption that every adult patient has the capacity to make
decisions about the disclosure of their personal information. You must not assume a patient
lacks capacity to make a decision solely because of their age, disability, appearance,
behaviour, medical condition (including mental illness), beliefs, apparent inability to
communicate, or because they make a decision you disagree with.

42 You must assess a patient’s capacity to make a particular decision at the time it needs to
be made, recognising that fluctuations in a patient’s condition may affect their ability to
understand, retain or weigh up information, or communicate their wishes.

36
43 We give detailed advice on assessing a patient’s mental capacity in our guidance Consent:
patients and doctors making decisions together. Practical guidance is also given in the Adults
with Incapacity (Scotland) Act 2000 and Mental Capacity Act 2005 codes of practice.14
Considering the disclosure

44 You may disclose personal information if it is of overall benefit to patient who lacks the
capacity to consent. When making the decision about whether to disclose information
about a patient who lacks capacity to consent, you must:

a. make the care of the patient your first concern

b. respect the patient’s dignity and privacy
c. support and encourage the patient to be involved, as far as they want and are able,
in decisions about disclosure of their personal information.

45 You must also consider:

a. whether the patient’s lack of capacity is permanent or temporary and, if temporary,

whether the decision to disclose could reasonably wait until they regain capacity
b. any evidence of the patient’s previously expressed preferences
c. the views of anyone the patient asks you to consult, or who has legal authority to
make a decision on their behalf, or has been appointed to represent them
d. the views of people close to the patient on the patient’s preferences, feelings,
beliefs and values, and whether they consider the proposed disclosure to be of
overall benefit to the patient
e. what you and the rest of the healthcare team know about the patient’s wishes,
feelings, beliefs and values.

46 You might need to share personal information with a patient’s relatives, friends or carers
to enable you to assess the overall benefit to the patient. But that does not mean they have
a general right of access to the patient’s records or to be given irrelevant information about,
for example, the patient’s past healthcare.

47 You must share relevant information with anyone who is authorised to make health and
welfare decisions on behalf of, or who is appointed to support and represent, a patient who
lacks capacity to give consent. This might be a welfare attorney, a court-appointed deputy
or guardian, or an independent mental capacity advocate. You should also share
information with independent mental health advocates in some circumstances.15

If a patient who lacks capacity asks you not to disclose

48 If a patient asks you not to disclose personal information about their condition or
treatment, and you believe they lack capacity to make that decision, you should try to
persuade them to allow an appropriate person to be given relevant information about their
care. In some cases, disclosing information will be required or necessary, for example under
the provisions of mental health and mental capacity laws (see paragraph 47).

37
49 If the patient still does not want you to disclose information, but you consider that it
would be of overall benefit to the patient and you believe they lack capacity to make that
decision, you may disclose relevant information to an appropriate person or authority. In
such cases, you should tell the patient before disclosing the information and, if appropriate,
seek and carefully consider the views of an advocate or carer. You must document in the
patient’s records your discussions and the reasons for deciding to disclose the information.

Disclosures for the protection of patients & others

Disclosing information to protect patients

50 All patients have the right to a confidential medical service. Challenging situations can
however arise when confidentiality rights must be balanced against duties to protect and
promote the health and welfare of patients who may be unable to protect themselves.
Disclosing information about children who may be at risk of harm

51 For specific guidance on confidentiality in the context of child protection, see our
guidance Protecting children and young people: the responsibilities of all doctors.16 For
general advice on confidentiality when using, accessing or disclosing information about
children and young people, see our guidance 0–18 years: guidance for all doctors.17
Disclosing information about adults who may be at risk of harm

52 As a rule, you should make decisions about how best to support and protect adult
patients in partnership with them, and should focus on empowering patients to make
decisions in their own interests. You must support and encourage patients to be involved, as
far as they want and are able, in decisions about disclosing their personal information.
Legal requirements to disclose information about adults at risk

53 There are various legal requirements to disclose information about adults who are
known or considered to be at risk of, or to have suffered, abuse or neglect.18 You must
disclose information if it is required by law.

You should:

a. satisfy yourself that the disclosure is required by law

b. only disclose information that is relevant to the request, and only in the way
required by the law
c. tell patients about such disclosures whenever practicable, unless it would undermine
the purpose of the disclosure to do so.

54 You can find advice about disclosures that are permitted but not required by law
in paragraphs 17 - 19.

38
Disclosing information to protect adults who lack capacity

55 You must disclose personal information about an adult who may be at risk of serious
harm if it is required by law (see paragraph 53). Even if there is no legal requirement to do
so, you must give information promptly to an appropriate responsible person or authority if
you believe a patient who lacks capacity to consent is experiencing, or at risk of, neglect or
physical, sexual or emotional abuse, or any other kind of serious harm, unless it is not of
overall benefit to the patient to do so.

56 If you believe it is not of overall benefit to the patient to disclose their personal
information (and it is not required by law), you should discuss the issues with an
experienced colleague. If you decide not to disclose information, you must document in the
patient’s records your discussions and the reasons for deciding not to disclose. You must be
able to justify your decision.

The rights of adults with capacity to make their own decisions

57 As a principle, adults who have capacity are entitled to make decisions in their own
interests, even if others consider those decisions to be irrational or unwise. You should
usually ask for consent before disclosing personal information about a patient if disclosure is
not required by law, and it is practicable to do so. You can find examples of when it might
not be practicable to ask for consent in paragraph 14.

58 If an adult patient who has capacity to make the decision refuses to consent to
information being disclosed that you consider necessary for their protection, you should
explore their reasons for this. It may be appropriate to encourage the patient to consent to
the disclosure and to warn them of the risks of refusing to consent.

59 You should, however, usually abide by the patient’s refusal to consent to disclosure, even
if their decision leaves them (but no one else) at risk of death or serious harm. 19, 20 You
should do your best to give the patient the information and support they need to make
decisions in their own interests – for example, by arranging contact with agencies to support
people who experience domestic violence.21 Adults who initially refuse offers of assistance
may change their decision over time.

Disclosing information to protect others

60 Doctors owe a duty of confidentiality to their patients, but they also have a wider duty to
protect and promote the health of patients and the public.22
Legal requirements to disclose information for public protection purposes

39
61 Some laws require disclosure of patient information for purposes such as the notification
of infectious diseases and the prevention of terrorism. You must disclose information if it is
required by law, including by the courts (see paragraphs 87 - 94).
Disclosing information with consent

62 You should ask for a patient’s consent to disclose information for the protection of
others unless the information is required by law or it is not safe, appropriate or practicable
to do so (see paragraph 14), or the information is required by law. You should consider any
reasons given for refusal.

Disclosing information in the public interest

63 Confidential medical care is recognised in law as being in the public interest. The fact that
people are encouraged to seek advice and treatment benefits society as a whole as well as
the individual. But there can be a public interest in disclosing information to protect
individuals or society from risks of serious harm, such as from serious communicable
diseases or serious crime.23

64 If it is not practicable or appropriate to seek consent, and in exceptional cases where a

patient has refused consent, disclosing personal information may be justified in the public
interest if failure to do so may expose others to a risk of death or serious harm. The benefits
to an individual or to society of the disclosure must outweigh both the patient’s and the
public interest in keeping the information confidential.

65 Such a situation might arise, for example, if a disclosure would be likely to be necessary
for the prevention, detection or prosecution of serious crime, especially crimes against the
person. When victims of violence refuse police assistance, disclosure may still be justified if
others remain at risk, for example from someone who is prepared to use weapons, or from
domestic violence when children or others may be at risk.

66 Other examples of situations in which failure to disclose information may expose others
to a risk of death or serious harm include when a patient is not fit to drive,24 or has been
diagnosed with a serious communicable disease,25 or poses a serious risk to others through
being unfit for work.26

67 Before deciding whether disclosure would be justified in the public interest you should
consider whether it is practicable or appropriate to seek consent (see paragraph 14). You
should not ask for consent if you have already decided to disclose information in the public
interest but you should tell the patient about your intention to disclose personal
information, unless it is not safe or practicable to do so. If the patient objects to the
disclosure you should consider any reasons they give for objecting.

68 When deciding whether the public interest in disclosing information outweighs the
patient’s and the public interest in keeping the information confidential, you must consider:

40
 a. the potential harm or distress to the patient arising from the disclosure – for
example, in terms of their future engagement with treatment and their overall
health
b. the potential harm to trust in doctors generally – for example, if it is widely
perceived that doctors will readily disclose information about patients without
consent
c. the potential harm to others (whether to a specific person or people, or to the public
more broadly) if the information is not disclosed
d. the potential benefits to an individual or to society arising from the release of the
information
e. the nature of the information to be disclosed, and any views expressed by the
patient
f. whether the harms can be avoided or benefits gained without breaching the
patient’s privacy or, if not, what is the minimum intrusion.

If you consider that failure to disclose the information would leave individuals or society
exposed to a risk so serious that it outweighs the patient’s and the public interest in
maintaining confidentiality, you should disclose relevant information promptly to an
appropriate person or authority.

69 You must document in the patient’s record your reasons for disclosing information with
or without consent. You must also document any steps you have taken to seek the
patient’s consent, to inform them about the disclosure, or your reasons for not doing so.

70 Decisions about whether or not disclosure without consent can be justified in the public
interest can be complex. Where practicable, you should seek advice from a Caldicott or data
guardian or similar expert adviser who is not directly connected with the use for which
disclosure is being considered. If possible, you should do this without revealing the identity
of the patient.
Responding to requests for information

71 You must consider seriously all requests for relevant information about patients who
may pose a risk of serious harm to others. For example, you must participate in procedures
set up to protect the public from violent and sex offenders, such as multi-agency public
protection arrangements (MAPPA) in England, Wales and Scotland and public protection
arrangements in Northern Ireland (PPANI).27 You must also consider seriously all requests
for information needed for formal reviews (such as inquests and inquiries, serious or
significant case reviews, case management reviews, and domestic homicide reviews) that
are established to learn lessons and to improve systems and services.
72 If you disclose personal information without consent, you must be satisfied that there is
a legal basis for breaching confidentiality (see paragraph 9). You must also be satisfied that
the other relevant requirements for disclosing information are met (see paragraph 10).
Disclosing genetic and other shared information

73 Genetic and some other information about your patient might also be information about
others with whom the patient shares genetic or other links. The diagnosis of a patient’s

41
illness might, for example, point to the certainty or likelihood of the same illness in a blood
relative.

74 Most patients will readily share information about their own health with their children
and other relatives, particularly if they are told it might help those relatives to:

a. get prophylaxis or other preventative treatments or interventions

b. make use of increased surveillance or other investigations
c. prepare for potential health problems.28

75 If a patient refuses to consent to information being disclosed that would benefit others,
disclosure might still be justified in the public interest if failure to disclose the information
leaves others at risk of death or serious harm (see paragraphs 63 - 70). If a patient refuses
consent to disclosure, you will need to balance your duty to make the care of your patient
your first concern against your duty to help protect the other person from serious harm.

76 If practicable, you should not disclose the patient’s identity in contacting and advising
others about the risks they face.

Using & disclosing patient information for secondary purposes

77 Many important uses of patient information contribute to the overall delivery of health
and social care. Examples include health services management, research, epidemiology,
public health surveillance, and education and training. Without information about patients
the health and social care system would be unable to plan, develop, innovate, conduct
research or be publicly accountable for the services it provides.

78 There are also important uses of patient information that are not connected to the
delivery of health or social care, but which serve wider purposes. These include disclosures
for the administration of justice, and for purposes such as financial audit and insurance or
benefits claims.

79 Anonymised information will usually be sufficient for purposes other than the direct care
of the patient and you must use it in preference to identifiable information wherever
possible. If you disclose identifiable information, you must be satisfied that there is a legal
basis for breaching confidentiality.
80 You may disclose personal information without breaching duties of confidentiality when
any of the following circumstances apply.

a. The disclosure is required by law, including by the courts (see paragraphs 87 - 94).
b. The patient has given explicit consent (see paragraph 95).
c. The disclosure is approved through a statutory process that sets aside the common
law duty of confidentiality (see paragraphs 103 - 105).
d. The disclosure can, exceptionally, be justified in the public interest (see paragraphs
106 - 112).

42
You must also be satisfied that the other relevant requirements for disclosing information
are met (see paragraph 10).

Anonymised information

81 The Information Commissioner’s Office anonymisation code of practice (ICO code)

considers data to be anonymised if it does not itself identify any individual, and if it is
unlikely to allow any individual to be identified through its combination with other
data.29 Simply removing the patient’s name, age, address or other personal identifiers is
unlikely to be enough to anonymise information to this standard.30

82 The ICO code also makes clear that different types of anonymised data pose different
levels of re-identification risk. For example, data sets with small numbers may present a
higher risk of re-identification than large data sets. The risk of re-identification will also vary
according to the environment in which the information is held. For example, an anonymised
data set disclosed into a secure and controlled environment could remain anonymous even
though the same data set could not be made publicly available because of the likelihood
of individuals being identified.

83 You should follow the ICO code, or guidance that is consistent with the ICO code, or seek
expert advice, if you have a role in anonymising information or disclosing anonymised
information.

The process of anonymising information

84 Information may be anonymised by a member of the direct care team who has the
knowledge, skills and experience to carry out the anonymisation competently, or will be
adequately supervised.

85 If it is not practicable for the information to be anonymised within the direct care team,
it may be anonymised by a data processor under contract, as long as there is a legal basis for
any breach of confidentiality (see paragraph 80), the requirements of data protection law
are met (see the legal annex) and appropriate controls are in place to protect the
information (see paragraph 86).

Disclosing anonymised information

86 If you decide to disclose anonymised information, you must be satisfied that appropriate
controls are in place to minimise the risk of individual patients being identified. The controls
that are needed will depend on the risk of re-identification, and might include signed
contracts or agreements that contain controls on how the information will be used, kept
and destroyed, as well as restrictions to prevent individuals being identified. You should
refer to specialist advice or guidance when assessing risk, or considering what level of
control is appropriate.31

43
Disclosures required by statutes or the courts

Disclosure required by statute

87 There are a large number of laws that require disclosure of patient information – for
purposes as diverse as the notification of infectious diseases, the provision of health and
social care services, the prevention of terrorism and the investigation of road accidents.

88 You must disclose information if it is required by law. You should:

a. satisfy yourself that personal information is needed, and the disclosure is required
by law
b. only disclose information relevant to the request, and only in the way required by
the law
c. tell patients about such disclosures whenever practicable, unless it would undermine
the purpose of the disclosure to do so
d. abide by patient objections where there is provision to do so. 32

89 You can find advice about disclosures that are permitted but not required by law
in paragraph 19.

Disclosing information to the courts, or to obtain legal advice

90 The courts, both civil and criminal, have powers to order disclosure of information in
various circumstances. You must disclose information if ordered to do so by a judge or
presiding officer of a court.

91 You should only disclose information that is required by the court. You should object to
the judge or the presiding officer if attempts are made to compel you to disclose what
appears to you to be irrelevant information, such as information about a patient’s relative
who is not involved in the proceedings. You should also tell the judge or the presiding officer
if you think disclosing the information might put someone at risk of harm.

92 If disclosure is ordered, and you do not understand the basis for this, you should ask the
court or a legal adviser to explain it to you. You should also tell the patient whose
information the court has asked for what information you will disclose in response to the
order, unless that is not practicable or would undermine the purpose for which disclosure is
sought.

93 You must not disclose personal information to a third party such as a solicitor, police
officer or officer of a court without the patient’s explicit consent, unless it is required by
law, or ordered by a court, or can be justified in the public interest. You may disclose
information without consent to your own legal adviser to get their advice.

44
94 In Scotland, the system of precognition means there can be limited disclosure of
information in advance of a criminal trial, to both the Crown and defence, without the
patient’s explicit consent. You should cooperate with precognition, but the disclosure must
be confined solely to the nature of injuries, the patient’s mental state, or pre-existing
conditions or health, documented by the examining doctor, and their likely causes. If they
want further information, either side may apply to the court to take a precognition on oath.
If that happens, you will be given advance warning and you should seek legal advice about
what you may disclose.33

Consent

95 You should ask for consent to disclose personal information for purposes other than
direct care34 or local clinical audit unless the information is required by law, or it is not
appropriate or practicable to obtain consent (see paragraph 14 for examples of when this
might be the case).

Disclosures for health and social care secondary purposes

Clinical audit

96 All doctors in clinical practice have a duty to participate in clinical audit35 and to
contribute to clinical outcome review programmes.36 If an audit is to be carried out by the
team that provided care, or those working to support them, such as clinical audit staff, you
may disclose personal information on the basis of implied consent, as long as you are
satisfied that it is not practicable to use anonymised information and that the patient:

a. has ready access to information that explains that their personal information may be
disclosed for local clinical audit, and they have the right to object
b. has not objected.

97 If a patient does object to personal information about them being included in a local
clinical audit related to their care, you should explain why the information is needed and
how this may benefit their current and future care. If the patient still objects, you should
remove them from the audit if practicable. If that is not practicable, you should make sure
this is explained to the patient, along with any options open to them.

98 If a clinical audit is to be carried out, but not by the team that provided care or those
working to support them, the information should be anonymised. If this is not practicable,
or if personal information is essential to the audit, you should disclose the information only
if you have the patient’s explicit consent or if there is another legal basis for breaching
confidentiality (see paragraph 80). You must also be satisfied that the other relevant
requirements for disclosing information are met (see paragraph 10).

Disclosures for financial or administrative purposes

45
99 If you are asked to disclose information about patients for financial or administrative
purposes, you should give it in an anonymised form, if that is practicable and will serve the
purpose. If identifiable information is needed, you must be satisfied that there is a legal
basis for breaching confidentiality (see paragraph 80).37 You must also be satisfied that the
other relevant requirements for disclosing information are met (see paragraph 10).

The professional duty of candour and confidentiality

100 All doctors have a duty of candour – a professional responsibility to be honest with
patients when things go wrong. As part of this duty, doctors must tell the patient when
something has gone wrong, and explain the short- and long-term effects of what has
happened.38

101 If the patient has died, or is unlikely to regain consciousness or capacity, it may be
appropriate to speak to those close to the patient. When providing information for these
purposes, you should still respect the patient’s confidentiality. If a patient has previously
asked you not to share personal information about their condition or treatment with those
close to them, you should abide by their wishes. You must still do your best to be
considerate, sensitive and responsive to those close to the patient, giving them as much
information as you can.

Openness and learning from adverse incidents and near misses

102 A number of reporting systems and schemes exist around the UK for reporting adverse
incidents and near misses. Organisations also have policies for reporting and responding to
adverse incidents and near misses and in some cases organisational duties of candour have
been written into law.39 If the law requires personal information to be disclosed for these
purposes, you should follow the guidance in paragraph 87. If the law does not require it, you
should ask for consent to disclose personal information unless it is not appropriate or
practicable to do so (see paragraph 14). In exceptional cases, disclosure may be justified
without consent in the public interest (see paragraphs 106 - 112).

Disclosures with specific statutory support

103 In England, Wales and Northern Ireland, statutory arrangements are in place for
considering whether disclosing personal information without consent for health and social
care purposes would benefit patients or the public sufficiently to outweigh patients’ right to
privacy. Examples of these purposes include medical research, and the management of
health or social care services. There is no comparable statutory framework in Scotland.

104 Section 251 of the National Health Service Act 2006 (which applies in England and
Wales) and the Health and Social Care (Control of Data Processing) Act (Northern Ireland)
2016 allow the common law duty of confidentiality to be set aside for defined purposes

46
where it is not possible to use anonymised information and where seeking consent is not
practicable. You can find more detail about these statutory arrangements in the legal annex.

105 You may disclose personal information without consent if the disclosure is permitted or
has been approved under regulations made under section 251 of the National Health
Service Act 2006 or under the Health and Social Care (Control of Data Processing) Act
(Northern Ireland) 2016. If you know that a patient has objected to information being
disclosed for purposes other than direct care, you should not usually disclose the
information unless it is required under the regulations.40

Public interest disclosures for health and social care purposes

106 In exceptional circumstances, there may be an overriding public interest in disclosing

personal information without consent for important health and social care purposes if there
is no reasonably practicable alternative to using personal information and it is not
practicable to seek consent. The benefits to society arising from the disclosure must
outweigh the patient’s and public interest in keeping the information confidential.

107 You should not disclose personal information without consent in the public interest if
the disclosure falls within the scope of any of the regulations described in paragraphs 103 -
105, and the disclosure is not permitted, or has not been approved, under those
regulations.

108 If the regulations described in paragraphs 103 - 105 do not apply, you may need to
make your own decision about whether disclosure of personal information without consent
is justified. The circumstances in which the public interest would justify such disclosures are
uncertain, however, so you should seek the advice of a Caldicott or data guardian or a legal
adviser who is not directly connected with the use for which the disclosure is being
considered before making the disclosure.41
109 Before considering whether disclosing personal information without consent may be
justified in the public interest, you must satisfy yourself that it is either necessary to use
identifiable information or not reasonably practicable to anonymise the information. In
either case, you must be satisfied that it is not reasonably practicable to seek consent.42

110 When considering whether disclosing personal information without consent may be
justified in the public interest, you must take account of the factors set out in paragraph 67.
You must also be satisfied that:

a. the disclosure would comply with the requirements of data protection law and
would not breach any other legislation that prevents the disclosure of information
about patients (see the legal annexfor examples)
b. the disclosure is the minimum necessary for the purpose
c. the information will be processed in a secure and controlled environment that has
the capabilities and is otherwise suitable to process the information (see paragraph
86)

47
 d. information is readily available to patients about any data that has been disclosed
without consent, who it has been disclosed to, and the purpose of the disclosure.

111 If you know that a patient has objected to information being disclosed for purposes
other than their own care, you should not disclose information in the public interest unless
failure to do so would leave others at risk of death or serious harm (see paragraphs 63 - 70).

112 You must keep a record of what information you disclosed, your reasons, and any
advice you sought.

Ethical approval for research

113 You should only disclose personal information for research if there is a legal basis for
the disclosure and the research has been approved by a research ethics committee.

114 If you are applying for ethical approval for research, you should let the research ethics
committee know if personal information will be disclosed without consent and tell them the
legal basis for the disclosure.

Requests from employers, insurers and other third parties

115 Third parties, such as a patient’s insurer or employer, or a government department, or

an agency assessing a claimant’s entitlement to benefits, may ask you for personal
information about a patient, either following an examination or from existing records. In
these cases, you should:

a. be satisfied that the patient has sufficient information about the scope, purpose and
likely consequences of the examination and disclosure, and the fact that relevant
information cannot be concealed or withheld
b. obtain or have seen written consent to the disclosure from the patient or a person
properly authorised to act on the patient’s behalf. You may accept an assurance
from an officer of a government department or agency, or a registered health
professional acting on their behalf, that the patient or a person properly authorised
to act on their behalf has consented
c. only disclose factual information you can substantiate, presented in an unbiased
manner, which is relevant to the request. You should not usually disclose the whole
record,43 although it may be relevant to some benefits paid by government
departments and to other assessments of a patient’s entitlement to pensions or
other health-related benefits
d. offer to show your patient, or give them a copy of, any report you write about them
for employment or insurance purposes before it is sent, unless:
i. they have already indicated they do not wish to see it
ii. disclosure would be likely to cause serious harm to the patient or anyone else
iii. disclosure would be likely to reveal information about another person who
does not consent.44, 45

48
116 If a patient refuses or withdraws consent, or if it is not practicable to get their consent,
you may still disclose information if it can be justified in the public interest (see paragraphs
63 - 70). You must disclose information if it is required by law (see paragraphs 87 - 94).

Managing and protecting personal information

Improper access and disclosure

117 Health and care records can include a wide range of material, including but not limited
to:

a. handwritten notes
b. electronic records
c. correspondence between health professionals
d. visual and audio recordings
e. laboratory reports
f. communications with patients (including texts and emails).

118 Many improper disclosures of patient information are unintentional. Conversations in

reception areas, at a patient’s bedside and in public places may be overheard. Notes and
records may be seen by other patients, unauthorised staff, or the public if they are not
managed securely. Patient details can be lost if handover lists are misplaced, or when
patient notes are in transit.

119 You must make sure any personal information about patients that you hold or control is
effectively protected at all times against improper access, disclosure or loss. You should not
leave patients’ records, or other notes you make about patients, either on paper or on
screen, unattended. You should not share passwords.

120 You must not access a patient’s personal information unless you have a legitimate
reason to view it.

121 You should not share personal information about patients where you can be overheard,
for example in a public place or in an internet chat forum.46 While there are some practice
environments in which it may be difficult to avoid conversations with (or about) patients
being overheard by others, you should try to minimise breaches of confidentiality and
privacy as far as it is possible to do so.

Knowledge of information governance and raising concerns

122 You must develop and maintain an understanding of information governance that is
appropriate to your role.

49
123 You should be satisfied that any members of staff you manage are trained and
understand their information governance responsibilities. If you are responsible for
employment contracts, you must make sure they contain obligations to protect
confidentiality and to process information in line with data protection law.

124 Unless you have a role in commissioning or managing systems, you are not expected to
assess the security standards of large-scale computer systems provided for your use in the
NHS or in other managed healthcare environments. If, however, you are concerned about
the security of personal information in premises or systems provided for your use, or the
adequacy of staff training on information governance, you should follow our advice
in Raising and acting on concerns about patient safety.47

Processing information in line with the data protection law

125 The General Data Protection Regulation read with the Data Protection Act 2018 sets out
the responsibilities of data controllers48 when processing personal data, as well as a
number of rights for individuals (known as data subjects). Detailed guidance is available on
the website of the Information Commissioner’s Office (ICO).49 You can find a summary of
the data protection principles in the legal annex to this guidance.

126 If you are a data controller, you must understand and meet your obligations under data
protection law. This includes responsibilities to make sure patients’ personal information
that you hold is handled in ways that are transparent and in ways that patients would
reasonably expect, and appropriate technical and organisational measures are in place to
guard against data loss. You must also make sure information is readily available to patients
that explains how their information is processed, including:

a. who has access to information you hold that might identify them and for what
purposes
b. their options for restricting access to some or all of their records
c. their rights to complain about how their information is processed, and how to make
a complaint.

When deciding how to provide this information, you should take into account the ICO’s
guidance on fair processing or privacy notices.50

127 Whether or not you are a data controller, you must be familiar with, and follow, the
confidentiality, data protection and record management policies and procedures where you
work and know where to get advice on these issues. This includes policies on the use of
laptops and mobile devices.

Records management and retention

128 If you are responsible for managing patient records or other patient information, you
must make sure the records you are responsible for are made, stored, transferred,
protected and disposed of in line with data protection law and other relevant laws. You

50
should make use of professional expertise when selecting and developing systems to record,
access and send electronic data.51

129 You must make sure any other records you are responsible for, including financial,
management or human resources records, or records relating to complaints, are kept
securely and are clear, accurate and up to date.52 You should make sure administrative
information, such as names and addresses, can be accessed separately from clinical
information so that sensitive information is not displayed automatically.

130 The UK health departments publish guidance on how long health records should be
kept and how they should be disposed of. You should follow the guidance, even if you do
not work in the NHS.53

The rights of patients to access their own records

131 Patients have a right to access their own health records, subject to certain
safeguards.54 You should respect, and help patients to exercise, their legal rights to have
access to, or copies of, their health records. The ICO gives guidance on what fees you may
charge.

Communicating with patients

132 Wherever possible, you should communicate with patients in a format that suits them.
For example, electronic communications – such as email or text messaging – can be
convenient and can support effective communication between doctors and patients, with
appropriate safeguards.55

133 Most communication methods pose some risk of interception – for example, messages
left on answering machines can be heard by others and emails can be insecure. You should
take reasonable steps to make sure the communication methods you use are secure.

Disclosing information after a patient has died

134 Your duty of confidentiality continues after a patient has died.56

135 There are circumstances in which you must disclose relevant information about a
patient who has died. For example:

 when disclosure is required by law

 to help a coroner, procurator fiscal or other similar officer with an inquest or fatal
accident inquiry57

 on death certificates, which you must complete honestly and fully

51
  when a person has a right of access to records under the Access to Health Records
Act 1990 or the Access to Health Records (Northern Ireland) Order 1993, unless an
exemption applies

 when disclosure is necessary to meet a statutory duty of candour.58

136 In other circumstances, whether and what personal information may be disclosed after
a patient’s death will depend on the facts of the case. If the patient had asked for
information to remain confidential, you should usually abide by their wishes. If you are
unaware of any instructions from the patient, when you are considering requests for
information you should take into account:

a. whether disclosing information is likely to cause distress to, or be of benefit to, the
patient’s partner or family59
b. whether the disclosure will also disclose information about the patient’s family or
anyone else
c. whether the information is already public knowledge or can be anonymised or de-
identified
d. the purpose of the disclosure.

137 Circumstances in which you should usually disclose relevant information about a patient
who has died include:

 the disclosure is permitted or has been approved under a statutory process that sets
aside the common law duty of confidentiality, unless you know the patient has
objected (see paragraphs 103 - 105)

 when disclosure is justified in the public interest to protect others from a risk of
death or serious harm

 for public health surveillance, in which case the information should be anonymised,
unless that would defeat the purpose

 when a parent asks for information about the circumstances and causes of a child’s
death

 when someone close to an adult patient asks for information about the
circumstances of that patient’s death, and you have no reason to believe the patient
would have objected to such a disclosure

 when disclosure is necessary to meet a professional duty of candour (see paragraphs

100 - 101)

52
  when it is necessary to support the reporting or investigation of adverse incidents, or
complaints, for local clinical audit, or for clinical outcome review programmes.60
138 Archived records relating to deceased patients remain subject to a duty of
confidentiality, although the potential for disclosing information about, or causing distress
to, surviving relatives or damaging the public’s trust will diminish over time. 61

Raising & Acting on concerns

Raising a concern

Duty to raise concerns

7All doctors have a duty to raise concerns where they believe that patient safety or care is
being compromised by the practice of colleagues or the systems, policies and procedures in
the organisations in which they work. They must also encourage and support a culture in
which staff can raise concerns openly and safely.

8 You must not enter into contracts or agreements with your employing or contracting body
that seek to prevent you from or restrict you in raising concerns about patient safety.
Contracts or agreements are void if they intend to stop an employee from making a
protected disclosure.3

Overcoming obstacles to reporting

9 You may be reluctant to report a concern for a number of reasons. For example, because
you fear that nothing will be done or that raising your concern may cause problems for
colleagues; have a negative effect on working relationships; have a negative effect on your
career; or result in a complaint about you.

10 If you are hesitating about reporting a concern for these reasons, you should bear the
following in mind.

a. You have a duty to put patients’ interests first and act to protect them, which
overrides personal and professional loyalties.
b. The law provides legal protection against victimisation or dismissal for individuals
who reveal information to raise genuine concerns and expose malpractice in the
workplace.4
c. You do not need to wait for proof – you will be able to justify raising a concern if you
do so honestly, on the basis of reasonable belief and through appropriate channels,
even if you are mistaken.

Steps to raise a concern

53
11 You must follow the procedure where you work for reporting adverse incidents and near
misses. This is because routinely identifying adverse incidents or near misses at an early
stage, can allow issues to be tackled, problems to be put right and lessons to be learnt.

12 If you have reason to believe that patients are, or may be, at risk of death or serious
harm for any reason, you should report your concern to the appropriate person or
organisation immediately. Do not delay doing so because you yourself are not in a position
to put the matter right.

13 Wherever possible, you should first raise your concern with your manager or an
appropriate officer of the organisation you have a contract with or which employs you –
such as the consultant in charge of the team, the clinical or medical director or a practice
partner. If your concern is about a partner, it may be appropriate to raise it outside the
practice – for example, with the medical director or clinical governance lead responsible for
your organisation. If you are a doctor in training, it may be appropriate to raise your
concerns with a named person in the deanery – for example, the postgraduate dean or
director of postgraduate general practice education.

14 You must be clear, honest and objective about the reason for your concern. You should
acknowledge any personal grievance that may arise from the situation, but focus on the
issue of patient safety.

15 You should also keep a record of your concern and any steps that you have taken to deal
with it.

Raising a concern with a regulator

16 You should contact a regulatory body such as the General Medical Council (GMC)5 or
another body with authority to investigate the issue (such as those listed at the end of this
guidance) in the following circumstances.

a. If you cannot raise the issue with the responsible person or body locally because you
believe them to be part of the problem.
b. If you have raised your concern through local channels but are not satisfied that the
responsible person or body has taken adequate action.
c. If there is an immediate serious risk to patients, and a regulator or other external
body has responsibility to act or intervene.

Making a concern public

17 You can consider making your concerns public if you:

a. have done all you can to deal with any concern by raising it within the organisation
in which you work or which you have contract with, or with the appropriate external
body, and
b. have good reason to believe that patients are still at risk of harm, and

54
 c. do not breach patient confidentiality.

But, you should get advice (see paragraph 18 below) before making a decision of this kind.

Help and advice

18 If you are not sure whether, or how, to raise your concern, you should get advice from:

a. a senior member of staff or other impartial colleague

b. the GMC’s Confidential Helpline6
c. your medical defence body, your royal college or a professional association such as
the British Medical Association (BMA)
d. the appropriate regulatory body listed at the end of this guidance if your concern
relates to a colleague in another profession, or other relevant systems regulators if
your concern relates to systems or organisations rather than individuals
e. Protect - A whistleblowing charity that advises and supports individuals and
encourages safe whistleblowing.

Acting on a concern

All doctors

19 All doctors have a responsibility to encourage and support a culture in which staff can
raise concerns openly and safely.

20 Concerns about patient safety can come from a number of sources, such as patients’
complaints, colleagues’ concerns, critical incident reports and clinical audit. Concerns may
be about inadequate premises, equipment, other resources, policies or systems, or the
conduct, health or performance of staff or multidisciplinary teams. If you receive this
information, you have a responsibility to act on it promptly and professionally. You can do
this by putting the matter right (if that is possible), investigating and dealing with the
concern locally, or referring serious or repeated incidents or complaints to senior
management or the relevant regulatory authority.

Doctors with extra responsibilities

21 If you are responsible for clinical governance or have wider management responsibilities
in your organisation, you have a duty to help people report their concerns and to enable
people to act on concerns that are raised with them.

22 If you have a management role or responsibility, you must make sure that:

a. there are systems and policies in place to allow concerns to be raised and for
incidents, concerns and complaints to be investigated promptly and fully7

55
 b. you do not try to prevent employees or former employees raising concerns about
patient safety – for example, you must not propose or condone contracts or
agreements that seek to restrict or remove the contractor’s freedom to disclose
information relevant to their concerns
c. clinical staff understand their duty to be open and honest about incidents or
complaints with both patients and managers
d. all other staff are encouraged to raise concerns they may have about the safety of
patients, including any risks that may be posed by colleagues or teams
e. staff who raise a concern are protected from unfair criticism or action, including any
detriment or dismissal.

Investigating concerns

23 If you are responsible for investigating incidents or complaints, you have a responsibility
towards those who raise a concern. You must:

a. protect them from unfair criticism or action, including any detriment or dismissal
b. tell them what action has been or will be taken to prevent a recurrence of the
problem (if this applies)
c. outline the process if they are still not satisfied with the response – for example, if
complaints are considered within the Local Authority Social Services and National
Health Service Complaints (England) Regulations 2009, the process for escalating the
concern to the Health Service Ombudsman.

24 If you are responsible for investigating incidents or complaints, you should also make
sure that:

a. any investigations or resulting actions are carried out in a way which is consistent
with the law, including, for example, the Public Interest Disclosure Act 1998 8
b. you have a working knowledge of the relevant law and procedures under which
investigations and related proceedings are carried out
c. those being investigated are treated fairly
d. appropriate adverse event and critical incident reports are made within the
organisation and to other relevant external bodies
e. recommendations that arise from investigations are put into practice or referred to
senior management
f. patients who make a complaint receive a prompt, open, constructive and honest
response.

25 You must also make sure that patients who suffer harm receive an explanation and,
where appropriate, an apology.9

Help and advice

26 If you are not sure how to act on a concern, you should get advice from:

56
 a. a more senior member of staff, your organisation’s management team or other
impartial colleague
b. your responsible officer or, if you are a responsible officer or medical director, a
GMC employer liaison adviser10
c. your medical defence body, royal college or a professional association such as the
BMA
d. the relevant regulatory authorities (such as the Care Quality Commission, the GMC,
or other professional regulators)
e. Protect, a whistleblowing charity that advises and supports individuals and
encourages safe whistleblowing.

Protecting children and young people: The responsibilities of all doctors

All children and young people1 are entitled to protection from abuse and
neglect. Good medical practice2 places a duty on all doctors to protect and promote
the health and well-being of children and young people. This means all doctors must
act on any concerns they have about the safety or welfare of a child or young
person.

Child protection is a difficult area of practice that can involve making decisions that
are emotionally challenging, complicated by uncertainty and sometimes go against
the wishes of parents.3 Doctors should work with parents and families, where
possible, to make sure that children and young people receive the care and support
they need. But in cases where the interests and wishes of parents may put the safety
of the child or young person at risk, doctors must put the interests of the child or
young person first.4 Failure to act when a child or young person is at risk can have
serious consequences for both the child and their family.

This guidance aims to help doctors to protect children and young people who are
living with their families or living away from home, including those being looked after
by a local authority.

In this guidance ‘abuse or neglect’ means physical, emotional or sexual abuse,

including fabricated or induced illness, and emotional or physical neglect, which has
led, or may lead, to significant harm to a child or young person. 5 6 7

All doctors have a duty to keep up to date with, and follow, the relevant laws, codes
of practice and guidance, including our advice in Good medical practice2 and 0–18
years: guidance for all doctors8 and our guidance on Confidentiality: good practice in
handling patient information9 and consent.10 These booklets provide more advice
on assessing capacity, and making decisions about treatment relating to the health
of children and young people.

In this guidance, the terms ‘you must’ and ‘you should’ are used in the following
ways.

 ‘You must’ is used for an overriding duty or principle.

57
 ‘You should’ is used when we are explaining how to meet the overriding duty.

 ‘You should’ is also used where the duty or principle will not apply in all situations or
circumstances, or where there are factors outside a doctor’s control that affect
whether or how a doctor can follow this guidance.

It is vital that all doctors have the confidence to act if they believe that a child or
young person may be being abused or neglected. Taking action will be justified,
even if it turns out that the child or young person is not at risk of, or suffering, abuse
or neglect, as long as the concerns are honestly held and reasonable, and the doctor
takes action through appropriate channels. Doctors who make decisions based on
the principles in this guidance will be able to justify their decisions and actions if we
receive a complaint about their practice.11

Principles for protecting children & young people

1 The following principles should guide all doctors who are concerned about the
safety or welfare of a child or young person.

a. All children and young people have a right to be protected from abuse
and neglect – all doctors have a duty to act on any concerns they have about
the safety or welfare of a child or young person.
b. All doctors must consider the needs and well-being of children and
young people – this includes doctors who treat adult patients.
c. Children and young people are individuals with rights – doctors must not
unfairly discriminate against a child or young person for any reason.12
d. Children and young people have a right to be involved in their own
care – this includes the right to receive information that is appropriate to their
maturity and understanding, the right to be heard and the right to be involved
in major decisions about them in line with their developing capacity (see the
advice on assessing capacity in appendix 1 to this guidance).
e. Decisions made about children and young people must be made in their
best interests – the factors to be considered when assessing best interests
are set out in appendix 2.
f. Children, young people and their families have a right to receive
confidential medical care and advice – but this must not prevent doctors
from sharing information if this is necessary to protect children and young
people from abuse or neglect.
g. Decisions about child protection are best made with others – consulting
with colleagues and other agencies that have appropriate expertise will
protect and promote the best interests of children and young people.
h. Doctors must be competent and work within their competence to deal
with child protection issues13 – doctors must keep up to date with best
practice through training that is appropriate to their role. Doctors must get
advice from a named or designated professional or a lead clinician or, if they
are not available, an experienced colleague if they are not sure how to meet
their responsibilities to children and young people.14

58
Identifying those at risk of, or suffering, abuse or neglect

Key points

 Be aware of risk factors that have been linked to abuse and neglect and look out
for signs that a child or young person may be at risk.
 If you are treating an adult patient, consider whether your patient poses a risk to
children or young people.
 Keep an open mind and be objective when making decisions. Work in partnership
with families where possible.
 If you are not sure about whether a child or young person is at risk or how best to
act on your concerns, ask a named or designated professional or a lead clinician
or, if they are not available, an experienced colleague for advice.

Roles of all doctors

2 You must consider the safety and welfare of children and young people, whether or
not you routinely see them as patients. When you care for an adult patient, that
patient must be your first concern, but you must also consider whether your patient
poses a risk to children or young people. You must be aware of the risk factors that
have been linked to abuse and neglect and look out for signs that the child or young
person may be at risk. Risk factors include having parents with mental health or
substance misuse issues, living in a home where domestic violence takes place, or
living in poverty.15 But these circumstances do not necessarily lead to abuse or
neglect, and child protection issues exist in all sections of society.

3 Identifying signs of abuse or neglect early and taking action quickly are important
in protecting children and young people. Working in partnership with parents and
families can help children and young people to get the care and support they need to
be healthy, safe and happy, and to achieve their potential. You should look out for
signs that a family may need extra support, and provide such support if that is part of
your role, or refer the family to other health or local authority children’s services so
they can get appropriate help.16

4 You must know what to do if you are concerned that a child or young person is at
risk of, or is suffering, abuse or neglect or, in the case of a pregnant patient, that the
child will be at risk of abuse or neglect after birth. This means you should have a
working knowledge of local procedures for protecting children and young people in
your area.17 You should know who your named or designated professional or lead
clinician is, or you should have identified an experienced colleague to go to for
advice, and know how to contact them.

59
5 You must act on any concerns you have about a child or young person who may
be at risk of, or suffering, abuse or neglect (see paragraphs 32 - 38).

Roles of doctors who work with children or young people

6 If you work with children or young people, you must have the knowledge and skills
to recognise signs and symptoms of abuse and neglect,2 3 4 9 11 12 13 and to take
appropriate and prompt action if necessary.

7 You must be open-minded when considering the possible cause of an injury or

other signs that may suggest that a child or young person is being abused or
neglected. For example, as part of the differential diagnosis you should consider
whether an uncommon condition, including a genetic condition, might have caused
or contributed to the child’s or young person’s injury or symptoms. You must also
make sure that the clinical needs of children and young people continue to be met
and are not overshadowed by child protection concerns.

8 You should work with parents and families, where possible, to make sure that
children and young people are receiving the care and support they need. This is
especially important for children and young people who are living in particularly
stressful circumstances – for example, because they are caring for a parent or their
parent is in hospital. You should be aware of services in your area that could provide
appropriate help, including, for example, services provided by voluntary groups.

9 In some cases, it may be difficult to identify where parents’ freedom to bring up

their children in line with their religious and cultural practices or beliefs becomes a
cause for concern about a child’s or young person’s physical or emotional well-
being.18 You should develop your understanding of the practices and beliefs of the
different cultural and religious communities you serve.

10 You must make sure your own cultural or religious background does not affect
your objectivity. When deciding whether to raise child protection concerns with
parents or with other agencies, you must consider the issues impartially and make
sure your personal views about parents’ and other adults’ religious and cultural
practices or beliefs do not affect your decisions about them or their family. If in doubt,
you should ask for advice from a professional or voluntary organisation that has
experience in working with a particular community. Or you should ask for advice from
a named or designated professional or a lead clinician or, if they are not available, an
experienced colleague.

11 If, having discussed the issues with the parents, you still have concerns that a
child or young person is at risk of, or is suffering, abuse or neglect, whatever the
cause, you must tell an appropriate agency (see the guidance in paragraphs 32–38).

12 If you are a named or designated professional or a lead clinician, you should

make sure your colleagues know what help you can offer and how to contact you for
advice and support.

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Communication & support

Key points

 Listen to children and young people and consider their views when making
decisions.
 Use communication methods that are appropriate to your patient group. Make
reasonable adjustments to provide information that children, young people and
their parents want or need to know, in a way they can understand.
 Tell children, young people and their parents when you have concerns about
abuse or neglect, and how you will act on these concerns, unless doing this may
put the child or young person, or anyone else, at risk of harm.
 Get advice if you are not sure what risks are associated with telling parents about
your concerns and how best to manage such risks.

Meeting communication needs

13 Meeting the language and communication needs of children, young people and
parents is important in any aspect of care, but it is especially important if you suspect
abuse or neglect. If you know in advance that child protection concerns will be
discussed during a consultation, you should make sure arrangements are in place to
meet the language and communication needs of the child or young person and their
parents. This might include, for example, using an independent advocate or
interpreter. If you suspect abuse or neglect, you must not rely on children or other
family members to interpret for the parents or depend on parents to interpret for the
child or young person.

14 You should be able to use methods of communication that are appropriate to your
patient group. For example, if you are communicating with very young children or
people with learning disabilities, you should be prepared to use methods such as
age-appropriate language, flash cards or signs to communicate effectively. Advice
and support from organisations with specialist knowledge of specific disabilities can
help you to meet the language or communication needs of children, young people or
parents who have particular disabilities.

Communicating with children and young people

15 Children and young people are individuals with rights that you must respect. You
must listen to children and young people and talk directly to them, taking into
account their age and maturity. You must answer their questions honestly and make
sure they know who they can go to for help or support (see Sources of independent

61
advice and support for parents and families for examples of organisations that can
give advice and support).

16 You must take children’s and young people’s views seriously and not dismiss
their concerns, fears or views because of their age. Even if children are not mature
enough to make decisions for themselves, their views and preferences are still
important and you must take them into account when assessing their best interests.
For more advice, see paragraphs 14 – 21 of 0–18 years: guidance for all doctors.8

17 In some cases, having a parent in the room during a consultation may discourage
a child or young person from being open about what has happened to them, or about
any concerns or fears they have. In these circumstances, you should consider
speaking to the child or young person without the parent present, in a suitable
environment and with appropriate support available to them – for example, by having
another health professional, an experienced colleague or a support person present.

Communicating with parents

18 Good communication with parents is essential. Parents generally want what is

best for their children and are experts in identifying when their child’s behaviour is
not normal for them and may be due to ill health. You should acknowledge parents’
understanding of their children’s health, particularly where a child’s age or disability
makes it difficult to communicate with them.

19 Most people do not intentionally harm children in their care. But a small number of
parents abuse or neglect their children and are dishonest when telling you about
events or their lifestyle. You must listen carefully to parents, children and young
people, explore inconsistent accounts and keep an open mind about the cause of a
child’s or young person’s injury or another sign that may suggest abuse or neglect.

20 You should normally discuss any concerns you have about a child’s or young
person’s safety or welfare with their parents. You should only withhold information
about your concerns, or about a decision to make a referral, if you believe that telling
the parents may increase the risk of harm to the child or young person or anyone
else. If this is difficult to judge, or you are not sure about the best way to approach
the situation, you should ask for advice from a designated or named professional or
a lead clinician or, if they are not available, an experienced colleague.

21 When discussing your concerns with parents, you should explain that doctors
have a professional duty to raise their concerns if they think a child or young person
is at risk of abuse or neglect. You should explain what actions you intend to take,
including if you are contacting the local authority children’s services. You should give
the parents this information when you first become concerned about a child’s or
young person’s safety or welfare and throughout a family’s involvement in child
protection procedures.

22 You must keep parents informed about what is happening, give them
opportunities to ask questions and be willing to answer their questions openly and
honestly. Being open and honest with families when concerns are raised about a

62
child’s or young person’s safety or welfare, and avoiding judgemental comments or
allocating blame, can encourage families to cooperate and help children and young
people stay with their families in safety. You should give parents information about
where they can get extra support and independent advice (see Sources
of independent advice and support for parents and families for examples of
organisations that can give advice and support).

Working in partnership

Key points

 Understand the roles of other professionals and agencies responsible for

protecting children and young people and work in partnership with them.
 Contribute to child protection procedures and provide relevant information to child
protection meetings if you are not able to go to them.
 Know who your named or designated professional or lead clinician is and how to
contact them.

Working jointly with others and communicating effectively

23 You must work with and communicate effectively with colleagues in your team
and organisation and with other professionals and agencies. This includes health
visitors, other nurses, social workers and the police.

24 You should understand and respect the child protection roles, responsibilities,
policies and practices of other agencies and professionals and cooperate with them.
You must be clear about your own role and responsibilities in protecting children and
young people and be ready to explain this to colleagues and other professionals.

25 You should make sure you have effective systems for communicating with health
visitors, child protection leads and other statutory agencies, either on a regular basis
or as the need arises. You must know who to contact and how to contact them.

Participating in child protection procedures

26 If you are asked to take part in child protection procedures, you must cooperate
fully. This should include going to child protection conferences, strategy meetings
and case reviews to provide information and give your opinion. You may be able to
make a contribution, even if you have no specific concerns (for example, general
practitioners are sometimes able to share unique insights into a child’s or young
person’s family).

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27 If meetings are called at short notice or at inconvenient times, you should still try
to go. If this is not possible, you must try to provide relevant information about the
child or young person and their family to the meeting, either through a telephone or
video conference, in a written report or by discussing the information with another
professional (for example, the health visitor), so they can give an oral report at the
meeting.

Confidentiality & Sharing Information

Key points

 Tell an appropriate agency promptly if you are concerned that a child or young
person is at risk of, or is suffering, abuse or neglect. Get advice if you are
concerned about the possibility of abuse or neglect, but do not believe that the
child or young person is at risk of significant harm.
 Ask for consent to share information unless there is a compelling reason for not
doing so. Information can be shared without consent if it is justified in the public
interest or required by law. Do not delay disclosing information to obtain consent
if that might put children or young people at risk of significant harm. Do not ask
for consent if you have already decided to disclose information in the public
interest.
 Tell your patient what information has been shared, with whom and why, unless
doing this would put the child, young person or anyone else at increased risk.
 Get advice if you are not sure what information to share, who to share it with or
how best to manage any risk associated with sharing information.

The principles of confidentiality

28 Confidentiality is central to the trust between doctors and patients and an

essential part of good care. Without assurances about confidentiality, children and
young people, as well as adults, may be reluctant to get medical attention or to give
doctors the information they need to provide good care.

29 Teenagers may be particularly concerned about keeping confidential information

from their parents, schools, children’s services, the police and other statutory
agencies. Young people, parents and other adults receiving psychiatric care, and
other vulnerable people might have similarly increased concerns about sharing
confidential information.

30 But sharing information appropriately is essential to providing safe, effective care,

both for the individual and for the wider community. It is also at the heart of effective

64
child protection. It is vital that all doctors have the confidence to act on their concerns
about the possible abuse or neglect of a child or young person.

31 Confidentiality is not an absolute duty.9 You can share confidential information

about a person if any of the following apply.

a. You must do so by law19 or in response to a court order.20

b. The person the information relates to has given you their consent to share the
information (or a person with parental responsibility has given consent if the
information is about a child who does not have the capacity to give
consent).21
c. It is justified in the public interest – for example, if the benefits to a child or
young person that will arise from sharing the information outweigh both the
public and the individual’s interest in keeping the information confidential.

Sharing information about those at risk

32 You must tell an appropriate agency, such as your local authority children’s
services, the NSPCC or the police, promptly if you are concerned that a child or
young person is at risk of, or is suffering, abuse or neglect unless it is not in their
best interests to do so (see paragraphs 39 and 40). You do not need to be certain
that the child or young person is at risk of significant harm to take this step. If a child
or young person is at risk of, or is suffering, abuse or neglect, the possible
consequences of not sharing relevant information will, in the overwhelming majority
of cases, outweigh any harm that sharing your concerns with an appropriate agency
might cause.

33 When telling an appropriate agency about your concerns, you should provide
information about both of the following:

a. the identities of the child or young person, their parents and any other person
who may pose a risk to them
b. the reasons for your concerns, including information about the child’s or
young person’s health, and any relevant information about their parents or
carers.

34 You should ask for consent before sharing confidential information unless there is
a compelling reason for not doing so. For example, because:

a. delay in sharing relevant information with an appropriate person or authority

would increase the risk of harm to the child or young person
b. asking for consent may increase the risk of harm to the child, young person,
you or anyone else.
c. you have already decided that disclosure is justified in the public interest.

35 You should ask the child or young person for consent if they have the capacity to
give it. If not, you should ask a person with parental responsibility. You should also
ask for consent from any adults you want to share information about. When asking

65
for consent, you should explain why you want to share information and how it will
benefit the child or young person. You should also explain all of the following:

a. what information you will share

b. who you will share it with
c. how the information will be used
d. where they can go for independent advice and support (see Sources of
independent advice and support for parents and families for examples of
organisations).

Sharing information without consent

36 You can share confidential information without consent if it is required by law, or

directed by a court, or if the benefits to a child or young person that will arise from
sharing the information outweigh both the public and the individual’s interest in
keeping the information confidential. You must weigh the harm that is likely to arise
from not sharing the information against the possible harm, both to the person and to
the overall trust between doctors and patients of all ages, arising from releasing that
information.

37 If a child or young person with capacity, or a parent, objects to information being

disclosed, you should consider their reasons, and weigh the possible consequences
of not sharing the information against the harm that sharing the information might
cause. If a child or young person is at risk of, or is suffering, abuse or neglect, it will
usually be in their best interests to share information with the appropriate agency.

38 If you share information without consent, you should explain why you have done
so to the people the information relates to, and provide the information described in
paragraph 35, unless doing this would put the child, young person or anyone else at
increased risk. You should also record your decision as set out in paragraph 54.

Delay in sharing information

39 Any decision to delay sharing information with an appropriate agency where a

child or young person is at risk of, or is suffering, abuse or neglect must be taken
cautiously and only in circumstances where the increased risk to the safety or
welfare of the child or young person clearly outweighs the benefits of sharing
information. You must be able to justify your decision. You must record the decision
not to immediately share information, along with your reasons and any advice you
have received.

40 If, exceptionally, you decide that sharing information immediately with the local
authority children’s services or another appropriate agency would not be in the
child’s or young person’s best interests, you should discuss this with the child or
young person, or their parents. You must keep in contact with the child or young
person and regularly review the decision to delay sharing information. You must try
to make sure that the child or young person gets the care and support they need.

66
41 In sharing concerns about possible abuse or neglect, you are not making the final
decision about how best to protect a child or young person. That is the role of the
local authority children’s services and, ultimately, the courts. Even if it turns out that
the child or young person is not at risk of, or suffering, abuse or neglect, sharing
information will be justified as long as your concerns are honestly held and
reasonable, you share the information with the appropriate agency, and you only
share relevant information.

Following up your concerns

42 You should follow up your concerns and take them to the next level of authority if
you believe that the person or agency you told about your concerns has not acted on
them appropriately and a child or young person is still at risk of, or is suffering, abuse
or neglect.

Minor concerns that might be part of a wider picture

43 Risks to children’s or young people’s safety and welfare often become apparent
only when a number of people share what seem to be minor concerns. This may
include people from different agencies. If a child’s or young person’s condition or
behaviour leads you to consider abuse or neglect as one possible explanation, but
you do not think that they are at risk of significant harm, you should discuss your
concerns with your named or designated professional or lead clinician or, if they are
not available, an experienced colleague. If possible, you should do this without
revealing the identity of the child or young person.

44 If your discussions do not provide a clear view about the possibility of abuse or
neglect, you should consider sharing limited relevant information with other agencies
that are in contact with the child or young person to decide whether there is a risk
that would justify sharing further information. Relevant information would include the
identity of the child or young person and a brief summary of the cause for concern.
You must ask for consent to do this as described in paragraph 35. If the person or
people you ask refuse to give consent, you should assess whether the possible
benefits of sharing information outweigh those of keeping the information confidential
as described as in paragraph 37.
45 If you are not satisfied that sharing information is justified in the circumstances,
you should regularly review the position, considering the safety and welfare of the
child or young person. You should encourage the parents, or child or young person,
to get help and support. If you later become concerned that the child or young
person is at risk of, or is suffering, abuse or neglect, you must tell an appropriate
agency as set out in paragraph 32.

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Responding to requests for information

46 You should consider all requests for information for child protection purposes
seriously and quickly, bearing in mind that refusing to give this information, or a
delay in doing so, could increase the risk of harm to a child or young person or
undermine efforts to protect them.

47 You must respond fully and quickly to a court order asking for information. You
must also cooperate with requests for information needed for formal
reviews22 carried out after a child or young person has died or been seriously
harmed and abuse or neglect is known, or is suspected, to have been a factor. The
purpose of such a review is to learn lessons from mistakes and to improve systems
and services for children and young people. You should also cooperate with
procedures set up to protect the public from violent and sex offenders.23

48 Before sharing confidential information, you should do all of the following.

a. Check the identity of the person who has asked for the information – for
example, by calling them back if you receive a telephone request from a
person or agency you do not recognise.
b. Check that the request is valid, understand why the person or agency is
asking for the information, what information they need, and how they may use
the information in the future.
c. Make sure that you have met one of the conditions for sharing information set
out in paragraph 31.

49 You should only share information that is relevant to the request. This will include
information about the child or young person, their parents and any other relevant
people in contact with the child or young person. Relevant information will include
family risk factors, such as drug and alcohol misuse, or previous instances of abuse
or neglect, but you should not usually share complete records. 24 If you share
information without consent you should follow the advice in paragraph 38.

50 If you are not sure whether to share information, you should discuss your
concerns and the best way to manage any risk to a child or young person with your
named or designated professional or lead clinician or, if they are not available, an
experienced colleague.

Sharing information in the healthcare team/others providing care

51 If a child or young person who is suspected to be at risk of, or suffering, abuse or

neglect is referred for specialist healthcare, you should make sure that you include
relevant information about the child protection concerns in the referral. You should
tell the child or young person, or parents, what has been shared and with whom
unless doing this would put the child, young person or anyone else at increased risk.

68
Child protection examination

Key points

 Get consent or other legal authorisation to carry out a child protection

examination.
 Make sure the person giving consent understands the purpose of the
examination, what it will involve and how the results of the examination might be
used.
 Respect a child’s or young person’s decision to refuse an examination.
 Avoid repeated examinations of a child or young person.

Carrying out a child protection examination

61 This guidance provides advice specifically on child protection examinations. A

child protection examination is carried out to look for signs that a child or young
person has been abused or neglected. This is different from a clinical examination,
which aims to establish what is wrong with the child or young person and what
treatment may be needed. We provide guidance on getting consent for clinical
examinations, investigations or treatment of children and young people in 0–18
years: guidance for all doctors.

62 Before carrying out a child protection examination, you must be satisfied that it is
necessary and appropriate in the circumstances. You should be clear about what it is
designed to achieve and whether the outcome is likely to affect the proposed course
of action. You should consider giving the child or young person the option of having
another adult present during the examination (this might be a parent, or an
independent chaperone, as appropriate).25 You must avoid repeated examinations
as these may be harmful to the child or young person.

Asking for consent

63 You need consent or other legal authorisation to carry out any child protection
examination, including a psychiatric or psychological assessment. You can get
consent or authorisation from:

a. a child or young person who has the maturity and understanding to make the
decision26
b. a person with parental responsibility if the child or young person does not
have the capacity to give consent (it is usually enough to have consent from
one person with parental responsibility)
c. the courts – for example, the family courts or the High Court.

69
64 You must be satisfied that the person giving consent understands the purpose of
the examination and what it will involve. This includes whether photographs or other
images will be taken and how the results of the examination might be used – for
example, as evidence in court.27 28 You must explain to the person that they have the
right to refuse consent, and what may happen if they do this. You must record the
discussion in the child or young person’s medical record.

65 If the police or another agency tells you that a person with parental responsibility
has given consent, you should check that the person has been given the information
described in paragraph 64.

66 You must keep to the terms of the consent. For example, if someone has given
consent for images to be taken for forensic purposes, you should not use the images
for other purposes – such as education or training – unless you get separate consent
to do this.

67 Advice on testing children and young people for a serious communicable disease
is set out in paragraphs 12–16 of our supplementary guidance Confidentiality:
disclosing information about serious communicable diseases. 28 30

When consent is not given

68 If a child or young person who has the capacity to consent refuses a child
protection examination, you should discuss with them their views and concerns
about the examination or what might happen afterwards. But you must respect their
decision, even if this may affect the quality of forensic evidence available. Children
and young people who are given the information and support they need, and allowed
to make decisions for themselves, may later change their decision.

69 Sometimes a child or young person may refuse consent because they are afraid
of the person who is abusing them, or because they are under pressure to refuse. If
you suspect this, you should consider the risk of harm to the child or young person
and discuss your concerns with your named or designated professional or lead
clinician or, if they are not available, an experienced colleague. If you are concerned
about the safety or welfare of the child or young person, you must follow the advice
set out in paragraphs 32 – 38.

70 If a child or young person refuses, or their parents refuse, to give their consent to
a child protection examination that you believe is necessary, and you believe that the
child or young person is at immediate risk of harm, you should contact the police and
local authority children’s services, which may take emergency action to protect them.
If you judge that the risk is not immediate, you should follow the advice set out
in paragraphs 32 - 38.

70
Assessing best interest

1. The ‘best interests’ of a child or young person should be the guiding principle in all
decisions that may affect them. Assessing a child’s or young person’s best interests will
include what is clinically indicated in a particular case. You should also consider:

a. the views of the child or young person, as far as they can express them, including
any preferences they have given in the past

b. the views of the parents

c. the views of other people close to the child or young person

d. the cultural, religious or other beliefs and values of the child or young person or
their parents

e. the views of other healthcare professionals

f. which choice, if there is more than one, will least restrict the child’s or young
person’s future options.

2. This is not a complete list. The importance you attach to each point will depend on the
circumstances, and you should consider any other relevant information. You should not
make unjustified assumptions about a child’s or young person’s best interests based on
irrelevant or discriminatory factors, such as their behaviour, appearance or disability.

...work in partnership with your patients...

The information that a doctor will give to a patient will vary from patient to patient. Some
patients will want to know everything about possible side effects of treatment, however
minor, and others would be happy with the bare essentials. At the least though, doctors
should tell patients about likely side effects, with an emphasis on anything that they may be
particularly concerned about. In Jason's case for example he was much more concerned
about a possible rise in his level of anxiety than another patient might be.

Discussing risk can be a complicated matter. For some treatments it would be impractical to
talk a patient through every possible risk, but not discussing risk at all can undermine a
patient's confidence in treatment. A balance must be struck, and doctors should discuss
with patients any risks which are likely to occur, and any that may be of particular concern
to them, and - where appropriate - refer them to other sources of information, such as the
leaflets accompanying prescription medicines. Guiding a patient through the risks and

71
benefits of each available option and emphasising which option the doctor believes to be
best for them, and why, will enable patients to make informed choices.

...openness, trust and good communication...

Everyone knows that doctors' time is limited, but taking time to build trust and encourage
patients to take an interest in their own healthcare can save time later on. Honesty is also
crucial to a trusting doctor-patient partnership, and it is important that doctors are honest
about the limits of their knowledge. It's fine for doctors to discuss with patients any policies
and procedures that might restrict their practice, as this can help patients to understand
their motives, building trust and encouraging patients to comply with treatment.

...listen to patients...
Doctors must listen carefully to what patients have to say, and what they're particularly
concerned about, even if it seems obvious straight away what the problem is. Many patients
- particularly those with long-term conditions - are experts in their condition, and how they
experience living with it. It's a doctor's duty to encourage patients to use this knowledge to
enable the patient to make informed decisions about their care. Responding to patients'
questions is also very important. It doesn't mean doctors have to take time to answer every
single question however irrelevant it may be; it just means that they should respond, even if
it's to assure them that it's not an issue.

..ensure that your prescribing is appropriate and responsible and in the patient's best
interests...
Doctors are able to prescribe unlicensed medicine, but before doing so they must be
satisfied that an alternative, licensed medicine will not satisfy the patient's needs. When
prescribing off-licence, a doctor would need to take responsibility for overseeing the
patient's care including monitoring and any follow-up treatment.

Good Medical Practice requires doctors to take account of the patient's views, support
patients in caring for themselves, and listen to patients, take account of their views, and
respond honestly to their questions. Nonetheless, we do not expect doctors to compromise
their clinical judgement in order to suit a patient's preferences. As long as a doctor
genuinely feels that that they treatment they have recommended would be in their
patient's best clinical interests, they would not be acting against our guidance by refusing to
prescribe an alternative treatment requested by the patient. Doctors should only prescribe
drugs to meet the identified needs of patients, and never simply because patients demand
them.

72
Dr Newell does not approve of abortion but has helped Katy to access appropriate care.
GMC guidance does not require doctors with a conscientious objection to abortion to refer
patients, even to another GP, provided that patients are able to access alternative care in
good time.
A Dr with a conscientious objection to abortion doesn’t have to refer pt to another doctor,
even to another GP, provided that patients are able to access alternative care in good time

References
You must explain to patients if you have a conscientious objection to a particular procedure.
You must tell them about their right to see another doctor and make sure they have enough
information to exercise that right. In providing this information you must not imply or
express disapproval of the patient's lifestyle, choices or beliefs. If it is not practical for a
patient to arrange to see another doctor, you must make sure that arrangements are made
for another suitably qualified colleague to take over your role.17
(Good Medical Practice paragraph 52)

You must not express your personal beliefs (including political, religious and moral beliefs)
to patients in ways that exploit their vulnerability or that are likely to cause them distress. 17
(Good Medical Practice paragraph 54)

You must not unfairly discriminate against patients or colleagues by allowing your personal
views to affect your professional relationships or the treatment you provide or arrange. You
should challenge colleagues if their behaviour does not follow this guidance, and follow the
guidance in paragraph 25c if the behaviour amounts to abuse or denial of a patient's or
colleague's rights.
(Good Medical Practice paragraph 59)

In line with the GMC Although prescribing over the phone may be appropriate in some
circumstances, doctors need to ensure that the medication will meet the patient's needs. An
adequate assessment of the patient's condition must be carried out and this will not always
be possible over the phone.

In line with the GMC Dr Newell judges that if Katy feels she really needs the medication
before her holiday, she will make an appointment for a proper assessment.

References
You must provide a good standard of practice and care. If you assess, diagnose or treat
patients you must:

73
a. Adequately assess the patient's conditions, taking account of their history (including the
symptoms and psychological, spiritual, social and cultural factors) and their views and
values. Where necessary, examine the patient.
(Good Medical Practice paragraph 15)

In providing clinical care you must:

b. prescribe drugs or treatment, including repeat prescriptions, only when you have
adequate knowledge of the patient's health, and are satisfied that the drugs or treatment
serve the patient's needs12 20
(Good Medical Practice paragraph 16)

...treat your patients with respect whatever their life choices and beliefs...
In the first scenario of Katy's case study, Katy is asking for help managing her panic attacks,
which seem to be connected to her illegal drug use. We're told that Dr Newell personally
disapproves of Katy's lifestyle. This, in itself, is not a problem - we don't expect doctors to be
robots without any views or feelings. However it would be a problem if a doctor's personal
views about a patient affected the professional relationship, or affected what treatment the
doctor was prepared to provide to that patient in particular.

So if Dr Newell had felt that, clinically, the best option for Katy was to prescribe her the
tranquillisers and/or refer her for counselling, but she didn't because she didn't feel that
Katy deserved to be offered the best option unless she changed her lifestyle, then this
would be contrary to our guidance. Good Medical Practice clearly tells doctors: You must
not refuse or delay treatment because you believe that a patient's actions or lifestyle
contributed to their condition. This has implications for patients who have conditions
relating to smoking or drinking or (like Katy) taking illegal drugs, and also to obese people.
Doctors have a duty to care for patients as best they can, whatever the cause of their illness.

Having said that, we don't expect doctors to avoid talking to patients about these things for
fear of offending them - on the contrary, Good Medical Practice states that doctors should
advise patients on how their lifestyle choices can affect their health and wellbeing.

..all patients are entitled to treatment and care to meet their clinical needs...
The GMC publishes guidance relating to personal beliefs - both doctors' and patients'. This
aims to clarify whether and to what extent we expect doctors to compromise their beliefs in
various circumstances. The ideal would be for doctors to be able to practise in accordance
with their beliefs, provided that patients receive effective and timely care, and are not
discriminated against.

74
At the same time, we wouldn't want a situation where a doctor felt justified in refusing to
treat particular groups of patients (for example members of the opposite sex, or gay people)
on the grounds of personal belief. The guidance allows the right to say no to a particular
procedure, but not to a particular patient or group of patients: that would be
discrimination.

Paragraph 52 of Good Medical Practice balances the doctor's right to hold a conscientious
objection to a particular procedure (such as abortion) and the patient's entitlement to care
and treatment to meet their clinical needs. GMC guidance does not require doctors with a
conscientious objection to abortion to refer patients, even to another GP, provided that
patients are able to access alternative care in good time. If patients don't have easy access
to other care options, depending on the urgency, we would expect doctors to be prepared
to set aside their personal beliefs in order to provide effective patient care.

...maintaining trust in the profession...

It wouldn't usually be appropriate for a doctor to raise the issue of their own personal
beliefs in the course of a consultation. If a doctor does find it necessary to explain their
personal beliefs to patients (perhaps because - as in this case study - it affects the treatment
they provide), the doctor must be careful not to cause the patient distress. If Dr Newell told
Katy that she "wouldn't play any part in killing an innocent child", for example, this would be
likely to upset Katy, particularly as she is already distressed and vulnerable.

This isn't to say that doctors must never say anything to patients that will cause them
distress - inevitably patients will sometimes get distressed by things doctors say - but this is
particularly in relation to those circumstances where doctors are required to explain their
personal beliefs to patients because they affect the care they are willing to provide.

...ensure that your prescribing is appropriate and responsible...

The final issue that is dealt with in Katy's case study is that of prescribing remotely. More
and more GP practices are offering telephone consultations and some doctors also
prescribe over the internet. The GMC does not prohibit these practices (with the exception
of injectable cosmetics) provided that an adequate assessment of the patient's condition is
still possible without seeing them in person, and provided that the doctor has adequate
knowledge of the patient's health and is satisfied that the treatment serves the patient's
needs (all principles in Good Medical Practice). However these requirements, which are set
out in more detail in our guidance on prescribing, are more likely to be met with a face to
face consultation.

75
Mrs Melville
But she won't support my decision. I think she's being over cautious and I really don't want
her to be involved if she's going to make things difficult for me. I don't understand why you
can't just take me at my word - I'm paying for the operation myself, I understand the risks
and I'm prepared to take them. Surely this is my decision?

It is important to establish any potential risk factors and patients may not always know what
these may be. If a doctor agrees not to inform a patient's GP they are then responsible for
all necessary after-care.

References
In providing clinical care you must:
a. prescribe drugs or treatment, including repeat prescriptions, only when you have
adequate knowledge of the patient's health and are satisfied that the drugs or treatment
serve the patients' needs.
f. check that the care or treatment you provide for each patient is compatible with any
other treatments the patient is receiving including (where possible) self-prescribed over-
the-counter medications
(Good Medical Practice, paragraph 16a and f)

You must contribute to the safe transfer of patients between healthcare providers and
between health and social care providers. This means you must:
a. share all relevant information with colleagues involved in your patients' care within and
outside the team, including when you hand over care as you go off duty, when you delegate
care or refer patients to other health or social care providers
(Good Medical Practice, paragraph 44a)

You must communicate clearly and respectfully with patients, listening to their questions
and concerns and considering any needs they may have for support to participate
effectively in decision making.
(Cosmetic interventions, paragraph 14)

If you believe the intervention is unlikely to deliver the desired outcome or to be of overall
benefit to the patient, you must discuss this with the patient and explain your reasoning. If,
after discussion, you still believe the intervention will not be of benefit to the patient, you
must not provide it. You should discuss other options available to the patient and respect

76
their right to seek a second opinion.
(Cosmetic interventions, paragraph 18)

You must consider whether it is necessary consult the patient's GP to inform the discussion
about benefits and risks. If so, you must seek the patient's permission and, if they refuse,
discuss their reasons for doing so and encourage them to allow you to contact their GP. If
the patient is determined not to involve their GP, you must record this in their notes and
consider how this affects the balance of risk and benefit and whether you should go ahead
with the intervention.
(Cosmetic interventions, paragraph 27)

You should give patients written information that explains the intervention they have
received in enough detail to enable another doctor to take over the patient's care. This
should include relevant information about the medicines or devices used. You should also
send this information, with the patient's consent, to their GP, and any other doctors treating
them, if it is likely to affect their future healthcare. If the patient objects to the information
being sent to their doctor, you must record this in their notes and you will be responsible for
providing the patient's follow-up care.
(Cosmetic interventions, paragraph 39)

Jenny
Yes Mr Yannis...well I didn't think we'd need consent for photos unless you can see their
face? I mean, who's going to know that's her leg?

Doctors used to be banned from advertising their services directly to the public. However,
Good Medical Practice has never prohibited advertising, provided that the information in
the ad is factual, verifiable and doesn't exploit patients' lack of medical knowledge

See what the doctor did

Mr Yannis decided to seek Mrs Horton's consent for the photo of her leg to be used in the
advert (she declined so he removed the photo). He checked GMC guidance about
advertising and contacted the Advertising Standards Authority to ensure the text of the
advert complied with their standards.

References
When advertising your services, you must make sure the information you publish is factual
and can be checked, and does not exploit patients' vulnerability or lack of medical

77
knowledge.
(Good Medical Practice, paragraph 70)

You must treat information about patients as confidential.

(Good Medical Practice, paragraph 50)

As a general rule, you should seek a patient's express consent before disclosing identifiable
information for purposes other than the provision of their care or local clinical audit, such as
financial audit and insurance or benefits claims.
(Confidentiality, paragraph 33)

If you cannot anonymise the information, you should seek the patient's consent before
disclosing it. When seeking the patient's consent, you must provide them with enough
information about the nature and purpose of the disclosure to enable them to make an
informed decision. This should include a description of the information to be disclosed and
an indication of how it will be used, for example, whether it will be published in a journal or
shown at a medical conference. You must then disclose that information only for the
purposes for which the patient has given consent.
You should respect a patient's refusal to consent to publication of their identifiable
information.
(Confidentiality: Disclosing information for education and training purposes, paragraphs 5
and 7)

When advertising your services, you must follow the regulatory codes and guidelines set by
the Committee of Advertising Practice.
(Cosmetic interventions, paragraph 47)

You must make sure the information you publish is factual and can be checked, and does
not exploit patients' vulnerability or lack of medical knowledge.
(Cosmetic interventions, paragraph 48)

Your marketing must be responsible. It must not minimise or trivialise the risks of
interventions and must not exploit patients' vulnerability. You must not claim that
interventions are risk free.
(Cosmetic interventions, paragraph 49)

78
You must not mislead about the results you are likely to achieve. You must not falsely claim
or imply that certain results are guaranteed from an intervention.
(Cosmetic interventions, paragraph 51)

Introduction
Mrs Melville comes back in seeking further facial surgery, and mentions that she would like
to make Mr Yannis a beneficiary in her will.

Accept Mrs Melville's offer, as he doesn't wish to offend her, but suggest she leaves the
money to his clinic rather than him personally?

Apologise and say he'll have to turn her kind offer down?

Say he can't deny her the right to make her will as she wishes, but that she shouldn't tell
him what she decides.

B - This answer best reflects GMC guidance.

This answer best reflects GMC guidance. Good Medical Practice states that doctors must not
accept any gift which might affect - or be seen to affect - their judgement. This applies even
though the inheritance would not be received until after Mrs Melville's death.

References
You must not ask for or accept - from patients, colleagues or others - any inducement, gift
or hospitality that may affect or be seen to affect the way you prescribe for, treat or refer
patients or commission services for patients.
(Good Medical Practice, paragraph 80)

...overall benefit to the patient...

Whenever a doctor provides or arranges treatment for a patient, they must do so on the basis of

what would be of overall benefit to the patient. While the vast majority of treatment decisions will

be medically indicated, the potential benefits stretch beyond strictly medical interests to include,

for example, psychological factors. This is the case with much cosmetic surgery - the doctor

decides that the risks of surgery are outweighed by the potential improvement in a patient's

mental health and general wellbeing that a positive outcome could achieve.

Having said that, while a patient's requests for treatment

79
A colleague’s behaviour

Background
Dr Quinn has recently been appointed a part-time GP in a busy inner-city practice
with four other GPs. She is concerned about the behaviour of Dr McCready, another
GP.

Scenario
Dr Quinn saw Dr McCready acting aggressively towards practice staff and has seen
some patients leave his consulting room visibly upset. A few patients have made
complaints about his dismissive, ill-tempered behaviour and the practice manager
reports that some patients have asked to be seen by other GPs, or the practice
nurse, instead of Dr McCready.

Dr Quinn is concerned that his behaviour will affect patient care if they are reluctant
to honestly discuss their symptoms and health concerns.

His behaviour is also affecting the previously positive working environment at the
practice and creating additional burden on other staff.

What the doctor did

Dr Quinn finds an opportunity to talk to Dr McCready about his behaviour. He tells

her that he has not been feeling his usual self because of personal problems but
provides assurances that everything is now under control.

He seems annoyed that she has raised the matter and doesn't want to discuss it any
further. However, soon after this Dr Quinn witnesses an angry outburst in the
practice waiting area and is concerned that Dr McCready doesn't appreciate the
seriousness of the situation.

Dr Quinn talks to Dr Ellis, the senior GP partner, about her concerns. He

understands the urgency of the situation and meets with Dr McCready to try to
identify the reasons behind his aggressive behaviour.

From the discussion, it emerges that Dr McCready's long term relationship has
recently ended and he is in the middle of distressing court proceedings about access
to his children. He admits he is angry and not coping with the stress and feels
exhausted. He is given special leave with immediate effect to deal with his family
situation. And he agrees to talk to the Doctor's Support Line about getting help to
develop other coping mechanisms for managing stress.

Dr McCready agrees that he will return to GP practice only when he feels ready and
able to effectively carry out his duties. As additional support, Dr Ellis arranges an
Occupational Health appointment for Dr McCready.

80
The practice manager sends letters of apology to the individual patients who had
previously complained. In the letter she reassures them that their concerns had been
taken on board and steps are being taken to ensure a better service in future.

Raising concerns with the right person

Background
Dr McDonald is ST5 and works on rotation on a geriatrics ward in Scotland.
She works as part of a multi-disciplinary team (MDT), with Nurse Wright, a
senior nurse who is particularly supportive.

The Health Board has a clear policy on hand washing as part of its drive to
reduce hospital acquired infections (HAI).

Scenario
During the time Dr McDonald has been working with Nurse Wright, she has
rarely seen her wash her hands after patient contact. This includes after
changing wound dressings and, on a number of occasions, when moving
between patients following procedures requiring mandatory hand washing.
Dr McDonald is worried about the heightened risk of HAIs on a ward with
elderly patients with multiple conditions, where such infections could have
serious consequences for their health.

Dr McDonald does not want to jeopardise her good working relationship

with Nurse Wright by confronting her about what she has seen. At the
same time, she knows that she cannot ignore the potential risk.

What the doctor did

Dr McDonald decides to talk with her Clinical Supervisor about her

concerns. He shares her concerns and tells her he will broach it with the
Ward Sister, Sister Jacob.

Following the meeting with the Clinical Supervisor, Sister Jacob has a one
to one meeting with Nurse Wright. She explains that her colleagues have
observed her not washing her hands and stresses that she must in future
follow the WHO five steps to hand hygiene at all times, in line with
the National Infection Prevention and Control Manual.

At the next safety briefing session, Sister Jacob reminds all staff of the risks
of HAIs, the increased risks on the geriatrics ward, and the importance of
taking extra care to follow hospital policy on hand washing practices.

81
...check that a named team has taken over
responsibility when your role has ended...
It is important to achieve good communication and coordination across health and social care

teams and services - so patients get the care they want, when they need it, in their preferred

place of care.

Good communication between healthcare team members, or between providers, is an essential

component of continuity of care for patients. It supports the patient's journey through the system

and ensures that information is shared in a timely way with the people who are best placed to

meet the patient's needs.

Vulnerable patients in particular may rely on their doctors to identify and anticipate their needs

and to share information to ensure they receive high quality care from all those involved in

treating and supporting them.

You must work in partnership with patients...

There is always a judgement to be made about how to deal with a patient who is refusing help that

you think they need. Doctors must be careful to respect a patient's autonomy if they, like Lesley,

are refusing help.

But it might be that they are reacting to a previous negative experience, eg having information

shared about them without their consent, or imagining the care will be more intrusive than it

actually is likely to be.

It's important to protect vulnerable patients but doctors must make sure that they work with

patients to come to decisions together about what care they need.

Patients who feel excluded from their care will be less likely to admit when they need help for fear

of their independence being taken away from them.

References
You must take prompt action if you think that patient safety, dignity or comfort is or may be

seriously compromised.

a. If a patient is not receiving basic care to meet their needs, you must immediately tell someone

who is in a position to act straight away.

(Good Medical Practice paragraph 25a)

82
All patients are entitled to food and drink of adequate quantity and quality, and to the help they

need to eat and drink...You should be satisfied that nutrition and hydration are being provided in a

way that meets your patient's needs and that if necessary patients are being given adequate help

to enable them to eat and drink

(Treatment and care towards the end of life: good practice in decision making paragraph 109)

If you are responsible for supervising staff, whatever your role, you must understand the extent of

your supervisory responsibilities, give clear instructions about what is expected and be available to

answer questions or provide help when needed. You must support any colleagues you supervise or

manage to develop their roles and responsibilities by appropriately delegating tasks and

responsibilities. You must be satisfied that the staff you supervise have the necessary knowledge,

skills and training to carry out their roles.

(Leadership and management for all doctors paragraph 62)

References
67. Some patients worry that towards the end of their life they may be given medical treatments

that they do not want. So they may want to make their wishes clear about particular treatments in

circumstances that might arise in the course of their future care. When discussing any proposed

advance refusal, you should explain to the patient how such refusals would be taken into account

if they go on to lose capacity to make decisions about their care.

68. If a patient lacks capacity and information about a written or verbal advance refusal of

treatment is recorded in their notes or is otherwise brought to your attention, you must bear in

mind that valid and applicable advance refusals must be respected. A valid advance refusal that is

clearly applicable to the patient's present circumstances will be legally binding in England and

Wales (unless it relates to life-prolonging treatment, in which case further legal criteria must be

met).1 Valid and applicable advance refusals are potentially binding in Scotland2 and Northern

Ireland3 although this has not yet been tested in the courts.1 The code of practice supporting the

Mental Capacity Act, which uses the legal term 'advance decision', sets out detailed criteria that

determine when advance decisions about life-prolonging treatments are legally binding - see the

legal annex.2 The code of practice supporting the Adults with Incapacity (Scotland) Act 2000,

which uses the legal term 'advance directive', gives advice on their legal status and how advance

directives should be taken into account in decisions about treatment.3 In Northern Ireland there is

no statutory provision or case law covering advance refusals, but it is likely that the principles

established in English case law precedents would be followed.

83
68. If a patient lacks capacity and information about a written or verbal advance refusal of

treatment is recorded in their notes or is otherwise brought to your attention, you must bear in

mind that valid and applicable advance refusals must be respected. A valid advance refusal that is

clearly applicable to the patient's present circumstances will be legally binding in England and

Wales (unless it relates to life-prolonging treatment, in which case further legal criteria must be

met).1 Valid and applicable advance refusals are potentially binding in Scotland2 and Northern

Ireland,3 although this has not yet been tested in the courts.1 The code of practice supporting the

Mental Capacity Act, which uses the legal term 'advance decision', sets out detailed criteria that

determine when advance decisions about life-prolonging treatments are legally binding - see the

legal annex.2 The code of practice supporting the Adults with Incapacity (Scotland) Act 2000,

which uses the legal term 'advance directive', gives advice on their legal status and how advance

directives should be taken into account in decisions about treatment.3 In Northern Ireland there is

no statutory provision or case law covering advance refusals, but it is likely that the principles

established in English case law precedents would be followed.

69. Written and verbal advance refusals of treatment that are not legally binding, should

be taken into account as evidence of the person's wishes when you are assessing whether a

particular treatment would be of overall benefit to them.

70. If you are the clinician with lead responsibility for the patient's care, you should assess both

the validity and applicability of any advance refusal of treatment that is recorded in the notes,

or that has otherwise been brought to your attention. The factors you should consider are different

in each of the the four UK countries, reflecting differences in the legal framework (see the legal

annex). However, in relation to validity, the main considerations are that:

a. the patient was an adult when the decision was made (16 years old or over in Scotland, 18

years old or over in England, Wales and Northern Ireland). b. the patient had capacity to make the

decision at the time it was made (UK wide).

c. the patient was not subject to undue influence in making the decision (UK wide).

d. the patient made the decision on the basis of adequate information about the implications of

their choice (UK wide).

e. if the decision relates to treatment that may prolong life it must be in writing, signed and

witnessed, and include a statement that it is to apply even if the patient's life is at stake (England

and Wales only ).

f. the decision has not been withdrawn by the patient (UK wide).

g. the patient has not appointed an attorney, since the decision was made, to make such decisions

on their behalf (England, Wales and Scotland).

84
h more recent actions or decisions of the patient are clearly inconsistent with the terms of their

earlier decision, or in some way indicate they may have changed their mind.

71. In relation to judgements about applicability, the following considerations apply across the UK:

a. whether the decision is clearly applicable to the patient's current circumstances, clinical

situation and the particular treatment or treatments about which a decision is needed.

b. whether the decision specifies particular circumstances in which the refusal of treatment should

not apply.

c. how long ago the decision was made and whether it has been reviewed or updated. (This may

also be a factor in assessing validity.)

d. whether there are reasonable grounds for believing that circumstances exist which the patient

did not anticipate and which would have affected their decision if anticipated, for example any

relevant clinical developments or changes in the patient's personal circumstances since the

decision was made

72. Advance refusals of treatment often do not come to light until a patient has lost capacity. In

such cases, you should start from a presumption that the patient had capacity when the

decision was made, unless there are grounds to believe otherwise.

73. If there is doubt or disagreement about the validity or applicability of an advance refusal of

treatment, you should make further enquiries (if time permits) and seek a ruling from the court if

necessary. In an emergency, if there is no time to investigate further, the presumption should be

in favour of providing treatment, if it has a realistic chance of prolonging life, improving the

patient's condition, or managing their symptoms.

74. If it is agreed, by you and those caring for the patient, that an advance refusal of treatment is

invalid or not applicable, the reasons for reaching this view should be documented.

(Treatment and care towards the end of life: good practice in decision making, paragraphs 67 -

74)

References
17. The people close to a patient can play a significant role in ensuring that the patient receives

high-quality care as they near the end of life, in both community and hospital settings. Many

parents, other close relatives and partners, as well as paid and unpaid carers, will be involved in

discussing issues with a patient, enabling them to make choices, supporting them to communicate

their wishes, or participating directly in their treatment and care. In some cases, they may have

85
been granted legal power by the patient, or the court, to make healthcare decisions when the

patient lacks capacity to make their own choices.

18. It is important that you and other members of the healthcare team acknowledge the role and

responsibilities of people close to the patient. You should make sure, as far as possible, that their

needs for support are met and their feelings respected, although the focus of care must remain on

the patient.

19. Those close to a patient may want or need information about the patient's diagnosis and about

the likely progression of the condition or disease, in order to help them provide care and recognise

and respond to changes in the patient's condition. If a patient has capacity to make decisions, you

should check that they agree to you sharing this information. If a patient lacks capacity to make a

decision about sharing information, it is reasonable to assume that, unless they indicate otherwise,

they would want those closest to them to be kept informed of relevant information about their

general condition and prognosis. (There is more guidance in our booklet on Confidentiality.) You

should check whether a patient has nominated someone close to them to be kept informed and

consulted about their treatment.

20. When providing information, you must do your best to explain clinical issues in a way the

person can understand, and approach difficult or potentially distressing issues about the patient's

prognosis and care with tact and sensitivity. (See paragraphs 33-36 on addressing emotional

difficulties and possible sources of support.)

21. When discussing the issues with people who do not have legal authority to make decisions on

behalf of a patient who lacks capacity, you should make it clear that their role is to advise the

healthcare team about the patient's known or likely wishes, views and beliefs. You must not give

them the impression they are being asked to make the decision.

(Treatment and care towards the end of life: good practice in decision making, paragraphs 17 -

21)

86