22: Clause 7, page 8, line 16, at end insert—
“(1A) In exercising the duty under subsection (1), no information may be shared by a specified authority, or an individual within a specified organisation, which breaches doctor/patient confidentiality as set out in the General Medical Council Ethical Guidance on confidentiality.”
My Lords, I beg to move Amendment 22 and will speak to Amendments 48, 54, 61, 64, 68 and 71, which all cover doctor-patient confidentiality in Clauses 7 to 17 in Part 2, Chapter 1 of the Bill.
I particularly thank the General Medical Council, the British Medical Association, the British Psychological Society and the British Association for Counselling and Psychotherapy for their briefings. I also thank the noble Lords, Lord Patel and Lord Ribeiro, who have added their names to these amendments. Their knowledge of and expertise in the regulatory and practical reality of doctor-patient confidentiality is especially welcome. Bluntly, the requirement for a specified authority to hand over data to police and other bodies, as set out in the Bill, is in conflict with the requirement of doctors and those working with patient data to maintain doctor-patient confidentiality.
It is particularly disappointing that the issues I will raise, which I also raised at Second Reading, were covered in the GMC response to the government consultation on a public health response to serious violence in 2019. Unfortunately, not one of the serious issues the GMC raised has been dealt with since then, which makes me wonder if this is deliberate. I hope the Minister will be able to demonstrate that that is not the case.
Our amendments seek to protect a patient’s data as confidential to them and the healthcare professionals who look after them. Amendment 22 adds to Clause 7 to make it clear that, regardless of any other data from other public bodies, patient medical data is protected by rules of confidentiality. Amendment 48 adds the same provisions to Clause 8, Amendments 61 and 64 add these to Clause 15 and Amendment 68 adds them to Clause 16. Amendment 54 deletes CCGs and health boards in Wales from the list of specified authorities, thus removing entirely the duty on them to be part of the regulations in this Bill. Finally, Amendment 71 reiterates these exclusions from the powers that Clause 17 gives the Secretary of State on the direction of CCGs and health boards in Wales.
My Lords, I support the amendments in this group in the name of the noble Baroness, Lady Brinton, to which I have added my name. The provisions in the Bill relating to serious violence introduce a new legal duty of disclosure that seriously threatens the doctor-patient relationship, especially in relation to patient confidentiality.
The Bill explicitly sets aside the common-law duty of confidentiality that I as a doctor owe to my patients. Doctors regard patient confidentiality as a fundamental ethical duty, upholding the trust that lies at the heart of the doctor-patient relationship. The Bill’s proposals that relate to disclosure of patient information threaten the common-law provision of confidentiality, the requirements of data protection laws and doctors’ ethical standards.
The General Medical Council, in guidance on professional standards, makes it clear to all doctors when and in what circumstances a doctor can release confidential patient information without a patient’s consent. This, in my view, covers the requirement for disclosure in situations of serious violence. The police having the ability to gain identifiable—I stress “identifiable”—patient information from health bodies without setting out clear reasons, which should be limited by statute, is fundamentally wrong. The Bill does not provide clear statutory arrangements that have the confidence of the medical profession, as highlighted by its regulator—the GMC—the BMA and some other health professionals, and, importantly, the data protection guardians. These bodies have raised serious concerns.
The noble Baroness, Lady Brinton, spoke eloquently and in detail on all the issues in moving her amendment, so I do not need to enlarge on that, but I support her comments. The Minister needs to set out more clearly the Government’s intention, scope and implementation of the powers in the Bill relating to access to patient data. The noble Baroness, Lady Brinton, asked some key questions that also cover some of my concerns. The issues are important. Might the Minister agree to meet the GMC, the BMA and representatives of other health professionals? I look forward to her response.
My Lords, I apologise for not having taken part in the Second Reading debate, when I was unavoidably abroad for professional reasons, or in the first Committee day, when unfortunately I was recovering from coronavirus—an experience I would not recommend to any of your Lordships given my experience of it. I rise to speak having very much enjoyed the speech by my noble friend Lord Patel, because I thought he introduced an element of balance that had not quite reached the debate in the earlier moments, eloquent as the introduction from the noble Baroness, Lady Brinton, was.
I will cite two pieces of my own experience as evidence. I spent 10 years as a lay member of the General Medical Council and, during those 10 years, sat successively on the health committee and the conduct committee. The health committee is a form of conduct committee, but with an obvious emphasis, as its name indicates. We spent a great deal of our time discussing whether doctors can be fully relied upon at all times, and in particular at critical moments, to understand the limits of the duty of confidentiality. Because it is not an absolute duty; there is a balance between the private rights of the patient and the general duty of the doctor not to disclose information, and the public duty of the doctor to disclose information if there is, for example, serious danger of violence to the public. I fear that more work will be needed on the amendments being proposed at the moment if that balance is to be sustained.
My second piece of evidence relates to an inquiry I conducted in 2012 for the then Secretary of State for Education, which related to something called the Edlington case. The brief story was that two small and neglected boys, who were fractionally over the age of criminal responsibility, nearly killed another child in a wood. Fortunately, that child and their companion survived—one of them only just. In my inquiry, I looked at the sharing of information by a host of organisations—schools, general practitioners, social workers and so on. It was a clear conclusion of my report that, if key information had been shared, the child who nearly died would not have been assaulted, the two very unfortunate little brothers who committed the assault would not have spent the succeeding years of their lives in a custodial institution and the schools would have been able to create a situation in which the dreadful problems for everybody concerned did not arise. One of the key issues in that case was that the general practitioners did not fully understand the balance between their duty to the public and the rights of their patient—and near-disaster ensued.
My Lords, I do not disagree with the noble Lord, Lord Carlile, but I none the less think that the noble Baroness, Lady Brinton, and her colleagues are on to something. There is no question but that the noble Lord, Lord Carlile, is right that, under common law, doctor-patient confidentiality is not and has never been absolute. The question is when it is trumped by other considerations, and who decides.
It is always dangerous to suspect what the Minister will say in her eventual reply, but I suspect that she will say reassuring things, and her colleagues will have given her reassuring things to say, about the intention. I am sure that the intention is not for the wholesale trumping of doctor-patient confidentiality. There is no public interest in that and the Government would not want people to take that as the case, because it would be completely counterproductive not just to the effective functioning of public health but to law and order. To give an obvious example, if everyone involved in knife crime feels that there will be no confidentiality whatever in the emergency room or elsewhere, one runs the danger of people not going to get the vital help and emergency care that they need. I know that the Minister will understand that.
Going back to the detail—as this is Committee—when should there be a trumping and who decides? That is a worthwhile, detailed conversation to be explored between organisations such as the General Medical Council and the Minister and her team. Because, while it may not be the Government’s intention to trump common-law principles of ethics and confidentiality en masse, we have to remember of course that statute displaces the common law. If the statute is unclear and people think or perceive that the common law has been trumped and that the decision has been taken completely out of the hands of an individual practitioner on the advice of ethical bodies or ultimately taken out of the hands of a judge and that the principles of confidentially have been totally trumped, we have a problem—and that means the Government have a problem as well.
My Lords, I am very minded to support this series of amendments. As the noble Baroness, Lady Brinton, and the noble Lord, Lord Patel, explained, doctor-patient confidentiality is far more than a common-law obligation. It is an ethical duty in a relationship of trust. Will the Minister consider whether the public understand what this aspect of the Bill compromises of that confidentiality?
Our doctors know a lot about us: the most intimate physical details, sometimes our psychological weaknesses, sometimes our darkest fears about life and death matters. While it has been a long time since we offered uncritical deference to our doctors, as patients and at our most vulnerable we are not equal partners and we need to trust that relationship, despite the power imbalance. So it is understandable that the General Medical Council and the British Medical Association are rightly worried that the Bill will smash the principle of confidentiality to bits.
The issue of confidentiality and trust will appear later in Committee in some other amendments that I shall speak to later, but my main question here is: why is this part of the Bill necessary? I genuinely do not understand. People involved in medical practice understand that, while confidentiality is an important legal and ethical duty, it is not an absolute. As the noble Lord, Lord Carlile, explained, it may be that some doctors get the balance wrong, but doctors are already expected to share confidential information if it is in the public interest, and that includes serious crime. However, this is presently understood as the exception, not the rule. At the moment, doctors need to consider the specific circumstances of what to share to satisfy the intended purpose and when to share it, and they have to weigh up the benefits and harms of disclosure.
Doctors are asked and trusted to exercise their professional judgment and to strike a balance between individual and community rights. I, for one, want to continue to trust medical personnel to make such judgments in good faith. Is the Minister saying that the Government do not trust them on this? It feels like an attack on professional discretion that will undermine doctors in the eyes of the public. At the moment, with the medical profession being under so much pressure and scrutiny—anger over no face-to-face GP appointments, tragic backlogs in hospital treatments—there is already tension between the public and the medical profession. If it comes out that when you go to the doctor, the sacred bond of confidentiality could in fact be expected to be broken, that will be very damaging for no good purpose.
My Lords, I have made no secret of the fact that I think that this is an appalling Bill. When I started looking at the amendments, I had to struggle not to sign up to all of them, because they all made sense, but I had to let my noble friend Lady Bennett of Manor Castle sign some, and she signed Amendment 48. She apologises for not being in her place today.
The noble Baroness, Lady Brinton, and the noble Lord, Lord Patel, laid out why all the amendments in this group are so important. Bringing together all the local authorities and other bodies to reduce serious violence is an excellent initiative, but it cannot come at the expense of breaching key safeguards for sensitive personal information, especially medical information. The amendments are about striking the right balance so that authorities can work together without being under a duty to breach doctor-patient confidentiality. Without this, we risk ever greater government intrusion into our personal and private lives in the vague name of keeping us safe—something this Tory Government seem to be very keen to do by quite repressive measures. By supporting the amendments, we can ensure that the Government do not overstep the mark.
My Lords, I support the principle behind the amendments but will make two short points to elaborate on what has already been said. First, I support what the noble Lord, Lord Carlile, said about balance. This has been referred to as a common-law duty, but the common law does not strike hard edges in such matters; it leaves room for balance to take account of particular circumstances.
At one stage in my career, when I was a senior judge in Scotland, I needed to know the state of health of one of my judges, who I knew was terminally ill with cancer. I was able to persuade his doctor, his skilled adviser, to let me know the truth when the judge himself was not prepared to do that. I felt that was the right thing to do; he thought it was the right thing to do; and it was an illustration of balance. The information remained entirely confidential between ourselves, but I had to take a decision as to the extent to which I could trust that judge to continue to sit in open court. The advice I received was very welcome: I was able to allow him to sit in certain conditions, in the light of the information I was given. I give that as an illustration of the way in which balance can operate in practical situations.
The other point to which I want to draw attention is the difference between Amendments 22 and 48. On the one hand, Amendment 22 states simply that
“no information may be shared … which breaches”
the duty set out in the General Medical Council ethical guidance on confidentiality. That is a simple formula that merely requires looking at the way the guidance is expressed; no doubt, with the balances that are built into the guidance. On the other hand, Amendment 48 says that regulations
“must not require the release of personal health information if a doctor regards that release as a breach”
My Lords, I support the principles of the amendments and declare my interest as a registered medical practitioner.
The debate in Committee has been most interesting in this regard, because it raises a delicate and deeply sensitive issue for any practising clinician—any practising healthcare professional—with the suggestion that something that is considered absolutely sacrosanct, the duty of confidentiality, may be in some way undermined.
That is, of course, not to neglect or fail to understand the fact that there are clear circumstances provided in the context of well-recognised and frequently applied professional guidance in which confidentiality may indeed be breached. But there is a suggestion that the way the Bill is drafted, there may be a deeply undermining impact on a very important principle, one that is so well recognised that it is protected in both data protection legislation and, as we have heard, common law. I wonder whether the Minister can explain why it is so important to achieve what are important objectives in the Bill that we need to undermine the common-law effect of such an important principle—confidentiality of medical information—and why they need to be promoted in the way proposed in the Bill. Have Her Majesty’s Government considered other ways to achieve their important objectives without creating this deep anxiety and uncertainty, because the full implications are clearly not well understood by the regulator or by professionals more generally, and which, we must therefore all feel, has the potential to be attended by consequences that could be deeply unhelpful to the nature and solidity of the doctor-patient relationship?
My Lords, I am well aware that we have some of the most senior lawyers in the country in the Committee today, and very senior doctors who have grappled with these issues, so perhaps I should put my point as a question. If the legislation provides for something that a doctor “regards”, is not the concept of reasonableness implied in that proposition, so the doctor must be reasonable in what he regards?
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It is quite extraordinary that this Bill proposes that any Home Secretary can, at will, demand that doctors and other healthcare professionals must breach patient confidentiality, over and above their responsibilities of confidentiality to their patients and their commitments to their regulatory body. Part 2, Chapter 1 of the Bill, on functions relating to serious violence, would introduce a new legal duty for the relevant agencies
“to collaborate, where possible through existing partnership structures, to prevent and reduce serious violence”.
If enacted in its current form, the Bill, particularly Clause 16(5), may mean that health services are no longer confidential. I hope this is unintended.
The Bill explicitly sets aside the common law duty of confidentiality owed to all patients by all regulated health professionals. This will undoubtedly raise questions and concerns in the minds of doctors, who understand their responsibilities around patient confidentiality as a fundamental, ethical duty which is crucial to upholding the trust that lies at the heart of doctor-patient relationships.
Elsewhere, in countries where healthcare services are not seen as confidential, and where there is a resulting lack of trust in healthcare professionals appropriately protecting as well as sharing information, there are real consequences for the health of individuals, communities and wider society. The public health implications of individuals and communities not interacting with healthcare services and professionals are particularly urgent and concerning in the context of the ongoing global Covid-19 pandemic. Unfortunately, as drafted the Bill carries these risks.
This is not just a concern for doctors. If you stopped anyone in the street and asked them if the personal medical information they discuss with their doctor at their GP surgery or at a hospital could be passed on to any other public body, including the police, they would be astonished. The one thing they know, they say, is that doctors—which is shorthand for healthcare service professionals and their staff—absolutely have to keep their personal medical data confidential. The problem is that it is not clear in the Bill whether sensitive health information is properly protected from inappropriate disclosure to policing bodies. This is worrying on two levels. First, the data is still subject to the requirements of data protection law. Also, any decision to disclose personal medical data must take account of the common law duty of confidentiality owed to patients by their health professionals, however that information is held.
Healthcare professionals, including doctors, also have to respond to the ethical standards set by their regulatory body. As drafted, policing authorities can request patient information, including identifiable information, which clinical commissioning groups and health boards in Wales must provide to them. Whatever the merits of this requirement, CCGs and Welsh health boards can share identifiable patient information only if that information has, in turn, been actively shared with them by the health professional who holds that patient data.
Professional standards, as regulated by the General Medical Council and the Nursing and Midwifery Council, among others, mean that doctors and other healthcare professionals are able to release confidential patient information, in this case to a CCG or health board, where one of the following conditions is met: the patient gives their consent; the doctor judges that it is in the best interests of the patient to do so; the law requires them to disclose, which would not be the case here; or they judge that the common-law test for disclosure without consent would be met. The GMC guidance to doctors, Confidentiality: Good Practice in Handling Patient Information, is very helpful in setting out where these boundaries lie, but makes it clear that it must be the decision of the individual doctor because, rightly, the natural assumption must be that personal patient data must be kept confidential.
The Minister may argue that the organisational duty to share information with a police authority or individual police officer would not impose a duty on an individual health professional to make a disclosure to the CCG or to health boards in Wales. That is a fallacy. I have a word of warning for the Government: imposing the duty on CCGs and health boards will not make it easier for identifiable patient information to be readily obtained by a policing body. That is because all staff in CCGs, health boards and GP surgeries, as part of their admin, and hospital staff who are not regulated but are part of a healthcare team are also subject to confidentiality duties as part of their employment contracts. They access patient records as part of their role and, in so doing, they will have to comply with the Data Protection Act and those contractual obligations about ethical confidentiality. This means that even if the common-law duty to protect confidentiality is not part of their contract, because they are not regulated, the relevant staff member, at whatever level in the organisation, would still have a duty to comply with the request from a policing body. If the Bill were to pass unamended and, say, CCGs and health boards decided to abide by the law under the Bill, could they put pressure on staff to release those records that they have accessed by virtue of their role that breaches GDPR?
I have some questions for the Minister, to better understand how the Bill will not destroy the confidentiality of patient data. Will its provisions mean that authorities such as CCGs and health boards in Wales—and integrated care boards, following the passage of the Health and Care Bill next year—will no longer owe a common-law duty of confidentiality to their patients, clients and service users? Will this mean that health services are no longer confidential services? If a duty to provide identifiable information to policing bodies is introduced, what provisions will be made for possible recourse for a patient or service user who finds out that their confidential information was shared with the police and considers that they suffered some unfair or unjustifiable detriment as a result? Will this be dependent on them being able to make a claim that GDPR obligations had not been met by the data controller? Most importantly, what independent safeguards, such as court orders or use of the court, are available to stop or limit the sharing or use of personal information?
Will the Government remove provisions that state that disclosures of information to the police would not breach that duty of confidentiality owed by doctors and others to patients, clients and service users? Will the Government instead work with the professional regulation, with the profession, with patient groups and others to create statutory guidance to support any new duty to collaborate? If the Government seek to retain provisions which require specified persons to share information, would anonymised information be sufficient? Will the Government commit to amending the Bill to provide that policing bodies can only request anonymous information?
I appreciate that the Minister might not have all the information in front of her to answer these questions, so will she write to me with the answers and have a meeting with me and the noble Lords, Lord Patel and Lord Ribeiro, who have added their names to these amendments? I know that the noble Lord, Lord Ribeiro, apologises for not being able to be in his place this afternoon. I beg to move.
To noble Lords moving these amendments and to the Minister, who I know listens to these debates extremely carefully, I say that this is not the time for people to take up closed positions on these matters. There is a lot of work to be done. I think my noble friend Lord Patel probably agrees with this, but I speak with great trepidation, because right in front of me are two of the most distinguished doctors in the whole country. We must ensure that, where it is necessary as a public duty, they and others need to be consulted to ensure that the balance is right and is therefore not the subject of the controversy we have been hearing about already this afternoon.
So I hope that, when the Minister eventually replies to this debate, she will not reject these concerns out of hand and will take on board the possibility of a bit more detailed discussion about when the duties to collaborate and so on should trump confidentiality, when not and, crucially, who is to decide. For my part, I would favour practitioners, properly advised, perhaps by more and further guidance from their professional bodies, and, if necessary in individual cases, by the order of a judge, possibly sought on an ex parte basis, as opposed to anything too wholesale or administrative. That is just my suggestion. I am sure that the Minister and her team will be able to come back with something that meets the concerns of the noble Baroness, Lady Brinton, and her colleagues before the next scrutiny stage of the Bill.
I rather wonder whether that would be the right way to go: to leave it up to the decision of a doctor without further consideration. With great respect to the medical profession, that may be taking a little bit of a risk, because there are situations where a doctor may feel under pressure and that would not be the right thing to do. I think the amendment would be strengthened by taking out the reference to the doctor and just laying it down as a matter of proper structure that the regulations should not require the duty of confidentiality, as set out in the guidance, to be breached, leaving individual doctors’ decisions out of it.