In most cases, you will need to make sure you have consent from the service user before you disclose or share any identifiable information
Working with other practitioners
One of the most common reasons for disclosing confidential information will be when you contact other health and care practitioners. This might include discussing a case with a colleague or referring a service user to another health and care professional.
Sharing information is part of good practice. Care is rarely provided by just one health and care professional, and sharing information within the multidisciplinary team or with other organisations or agencies is often an important way of making sure care can be provided effectively.
Most service users will understand the importance of sharing information with others who are involved in their care or treatment and will expect you to do so, so you will normally have implied consent to do this.
However, when you share information with other colleagues, you should make sure that:
- it is necessary to provide the information;
- you only disclose the information that is relevant; and
- the professional receiving the information understands why you are sharing it and that they have a duty to keep it confidential.
If you decide not to contact other practitioners when you might reasonably be expected to, or if a service user asks you not to, it is important that you keep clear records of this and are able to justify your decision.
If you are concerned about a request someone makes for information – for example, you think the information they have asked for is not relevant – you should contact the person who has asked for the information so they can explain their request. You may also want to get legal advice, or advice from a union or professional body if you are a member.
It is important that you get express consent, in writing where possible, if you plan to use identifiable information for reasons which are not directly related to the service user’s care or if they would not reasonably expect their information to be used or shared in that way.
Examples might be where you need information for research, teaching or health and care services planning. In many cases it will be sufficient to use information which does not identify the service user. Where possible, it is better to use this than to use identifiable information. You should consider how much information you need to change or remove to make sure that you are protecting the service user’s confidentiality. For example, you should consider whether the area you work in means that it might be possible to identify the service user by their job or by their medical condition.
If you need to use identifiable information, you should explain fully to the service user how you will use their information and whether there are any risks involved in disclosing it. You should make sure that their consent is clearly recorded in their notes.
Sometimes, a third party who is not a health and care professional may ask you for information. This might be a request to send information to an insurance company, government agency or a solicitor. You should make sure that you have express consent to provide any information.
In these situations, you should also keep a written record of the information you have disclosed and only disclose what you have been asked to. You should also offer to show the service user or provide a copy of any report you write about them for such purposes.
If a service user does not give their consent
- You should make sure that you explain to the service user the possible effect of not sharing information about their care or other services you are providing.
- If a service user who has capacity refuses to give consent for information to be shared with other health and care professionals involved in providing care, treatment or other services, you must respect their decision, even if it could negatively affect the care, treatment or other services they can receive.
- However, if the law says you must disclose the information or it is justified in the public interest to do so, you can do so without the consent of the service user. We explain more about situations like this later in this guidance.