The aims of the policy are to ensure

  • all information held at the Practice about patients is confidential, whether held electronically or in hard copy
  • sexual orientation, gender identity and trans status are protected data
  • other information about the Practice (for example its financial matters, staff records) is confidential
  • all staff are aware of their responsibilities for safeguarding confidentiality and preserving information security
  • all staff understand their responsibilities when sharing information with both NHS and non-NHS organisations

Staff will, by necessity, have access to such confidential information from time to time


The policy applies to all employees and partners, and also applies to other people who work at the practice e.g. self-employed staff, temporary staff and contractors – collectively referred to herein as ‘workers’.


  • All information about patients is confidential: from the most sensitive diagnosis, to the fact of having visited the surgery or being registered at the practice. This includes information about patients’ families or others associated with them.
  • Confidential information may not be health-related. It can include anything that is private and not public knowledge.
  • Workers should limit any discussion about confidential information to only those who need to know within the practice.
  • Only the minimum amount of necessary information should be disclosed
  • The duty of confidentiality owed to a person under 16 is as great as the duty owed to any other person.


  • Workers must not under any circumstances disclose patient information to anyone outside the practice, except to other health professionals on a need-to-know basis, or where the patient has provided written consent.
  • Workers must not under any circumstances disclose other confidential information about the practice to anyone outside the practice unless with the express consent of Dr Wong.
  • All patients can expect that their personal information will not be disclosed without their permission (except in the most exceptional circumstances when disclosure is required when a person is at grave risk of serious harm).
  • Where disclosure of information is required which is non-routine in nature the patient will, where possible, be fully informed of the nature of the disclosure prior to this being released.
  • Where the decision is made to disclose information, the decision to do so must be justified and documented.
  • Person-identifiable information must not be used unless absolutely necessary – anonymised date should be used wherever possible.
  • Workers must be aware of and conform to the requirements of the Caldicott recommendations.
  • Electronic transfer of any confidential information, once approved by the [Practice Manager/Senior Partner], must be transmitted via the NHSnet. Workers must take particular care that confidential information is not transmitted in error by email or over the Internet. See also: Electronic Transfer of Patient Data Policy [*]
  • Workers must not take data from the practice’s computer systems (e.g. on a memory stick or removable drive) off the premises unless authorised to do so by Dr Wong.
  • Where this is the case, the information must be kept on the worker’s person at all times while travelling and kept in a secure, lockable location when taken home or to another location. All information should be held on an encrypted disc, or pendrive
  • Workers who suspect a breach of confidentiality must inform the [Practice Manager/Senior Partner]
  • Any breach of confidentiality could be considered a serious disciplinary offence and will be investigated in line with the practice’s disciplinary procedure.
  • Workers remain bound by a requirement to keep information confidential even if they are no longer employed at the practice. Any breach, or suspected breach, of confidentiality after the worker has left the practice’s employment will be passed to the practice’s lawyers for action

Responsibilities of Practice Staff/Workers

All health professionals must follow their professional codes of practice and the law. This means that they must make every effort to protect confidentiality. It also means that no identifiable information about a patient is passed to anyone or any agency without the express permission of that patient, except when this is essential for providing care or necessary to protect somebody’s health, safety or well-being.

All health professionals are individually accountable for their own actions. They should, however, also work together as a team to ensure that standards of confidentiality are upheld, and that improper disclosures are avoided.

Additionally, Dr Wong, Ashton View Medical Centre, as Employers:

  • are responsible for ensuring that everybody employed by the practice understands the need for, and maintains, confidentiality.
  • have overall responsibility for ensuring that systems and mechanisms are in place to protect confidentiality.
  • have vicarious liability for the actions of those working in the practice – including health professionals and non-clinical staff (i.e. those not employed directly by the practice but who work in the surgery).


Standards of confidentiality apply to all health professionals, administrative and ancillary staff – including receptionists, secretaries, practice manager, cleaners and maintenance staff – who are bound by contracts of employment to maintain confidentiality.

They must not reveal personal information they learn in the course of their work, or due to their presence in the surgery, to anybody outside the practice without the patient’s consent. Nor will they discuss with colleagues any aspect of a patient’s attendance at the surgery in a way that might allow identification of the patient, unless to do so is necessary for the patient’s care.

Gender Recognition Act 2004

The 2004 Gender Recognition Act (GRA) makes it a criminal offence to disclose an individual’s transgender history to a third party without their written consent if that individual holds a Gender Recognition Certificate (GRC). Patients do not need to show a GRC or birth certificate in order for the GRA 2004 to be in effect, so it is best practice to act as though every trans patient has one. This means always obtaining a trans patient’s written consent before sharing details about their social or medical transition, sometimes also called gender reassignment, with other services or individuals. This includes information such as whether a patient is currently taking hormones or whether they have had any genital surgery, as well as information about previous names or the gender they were given at birth. Consent should always be obtained before information relating to the patient being trans is shared in referrals and this information should only be shared where it is clinically relevant, e.g. it would be appropriate when referring a trans man for a pelvic ultrasound but not when referring him to ENT.

If Disclosure is Necessary

If a patient or another person is at grave risk of serious harm that disclosure to an appropriate person would prevent, the relevant health professional can take advice from colleagues within the practice, of from a professional / regulatory / defence body, in order to decide whether disclosure without consent is justified to protect the patient or another person. If a decision is taken to disclose, the patient should always be informed before disclosure is made, unless to do so could be dangerous. If at all possible, any such decisions should be shared with another member of the practice team.

Any decision to disclose information to protect health, safety or well-being will be based on the degree of current or potential harm, not the age of the patient.