Medical reports - dealing with requests

Doctors are frequently requested to provide information about their patients. These requests come from a variety of sources - eg, employers, government agencies and regulatory bodies. In the UK, GPs receive the most requests, as it is they who hold the most comprehensive records.

Information may need to be provided in the form of a medical report, a certificate, a statement or a letter. Most requests for information present no problem but occasional difficulties may arise. Such difficulties may include conflicts of interest, unreasonable expectations about the information the doctor may hold and problems about payment. Classifying the medical reports may help to clarify these issues.

Table 1. Medical reports in British general practice¹

Some application forms (eg, FP92A and FW8) can now be completed online² .

Classes of medical reports¹

Legal reports that advance patient care

These will include recommendations under the Mental Health Act, child protection reports and assessment of mental capacity. It should be remembered that these are legal documents which come under different rules of consent from referrals for investigation and treatment.

The public good

Doctors have an obligation to act in the public good. Examples of doctors exercising their public health function include medical reports in notification of infectious diseases and adverse drug reactions. Death certification, cremation certificates and medical reports to coroners provide important epidemiological information.

Consent is usually not required where doctors are legally obliged to provide medical reports but it is good practice to inform the patient where possible.

Illness as an entitlement or excusing factor

This is the largest and most controversial category. A satisfactory system has yet to be found which ensures that patients using illness as an excusing factor are able to obtain sickness benefit without making unfair claims on the public purse³ . A variety of forms cover various circumstances in which sickness benefit or incapacity benefit is claimed. See also the separate Sickness Certification in Primary Care article.

Other situations in which a certificate is requested in this category include jury service, attendance at court, probation, or community punishments.

Certificates or medical reports may also be requested to enable patients to access benefits such as free prescriptions, free travel on public transport, preferential access to social housing and parking.

Fitness for sports

Reports certifying that a patient is fit to take part in sport may involve hazardous activities, such as bungee-jumping, or more mundane sports, such as gym training. Individuals are now actively discouraged from asking GPs to sign firearms certificates. Criteria vary and some bodies which may be considered to organise hazardous sports, such as the British Sub-Aqua Club, have abandoned reports altogether. There is rarely a conflict with the organising body if a doctor declares a patient unfit but the patient themself may object if they feel a health problem is irrelevant.

Fitness for an occupation

This may include driving (heavy goods vehicles and passenger-carrying vehicles) and health professions, such as occupational therapy and physiotherapy. The common theme is that those unfit to practise may pose a physical or mental risk to the public. Detailed guidance on relevant health factors is provided by the Driver and Vehicle Licensing Agency and taxi licensing authorities. See also the separate Fitness to Drive article.

Many health professionals in this category work for themselves or are licensed to work for a number of different employers. Work which is only possible in large organisations (eg, driving trains, flying commercial aeroplanes) normally comes under the purview of the company's own occupational health service.

The focus is on the public good rather than the risk to individual workers. Concern for patients rather than practitioners is the guiding principle of the Health Professions Council in identifying those whose illness may affect their practice⁴ .

Information for actuarial assessments

These are commonly known as insurance or personal medical attendant (PMA) reports. Their principal function is to help insurers assess an individual's risk of disability or death and weight premiums accordingly (or in rare cases refuse insurance altogether). The framework governing the reports is clear and doctors writing them are obliged to give clear and accurate information even if this is to the disadvantage of the patient. Since patients may not know what information is to be divulged, consent is generally carefully worded. It usually includes an option for an independent medical assessment if a GP cannot, or will not, provide a medical report, and provision for patients to view the information in the report and withhold information that they do not want divulged⁵ .

A common format for General Practitioner Report (GPR) has been agreed and computer-generated reports (eGPR) are accepted by insurers. Many GP software programs now have the facility to generate reports from within their systems, merging all relevant patient data. It is, however, still necessary for the GP to check that the data are complete and accurate before submitting the medical report⁵ .

Non-medical reports

Countersigning passport applications and confirming identity are examples. In 2001, Tony Blair commenced an initiative to reduce paperwork in general practice and this has had an effect on reducing the number of requests for these types of medical reports⁶ . The British Medical Association has continued this initiative over the years and has produced a number of templates GPs can use to reduce requests for inappropriate workload from a variety of sources⁷ .

Ethical problems¹

Consent

If the patient requests the medical report, consent may be implied or signed consent may be given. Signed consent does not always mean informed consent and consent may be the only way to obtain insurance or benefits or take part in some activity. The right to see a medical report prior to submission is therefore important but legislation does not cover all reports. There may be a tension between the interests of the patient, the requirements of a third party and the obligations of a doctor to provide accurate information.

Table 2. Ethical issues in medical reports¹

General Medical Council guidance

The General Medical Council (GMC) guidance, Confidentiality: disclosing information for insurance, employment and similar purposes (2017), states⁸ :

The first duty of a doctor registered with the GMC is to make the care of their patient their first concern. You must inform patients about disclosures for purposes they would not reasonably expect, or check that they have already received information about such disclosures. 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.

If you are asked to provide information to third parties, such as a patient's insurer or employer or a government department or an agency assessing a claimant's entitlement to benefits, either following an examination or from existing records, you should:

• 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.

• 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.

Only disclose factual information you can substantiate, presented in an unbiased manner, relevant to the request and offer to show your patient, or give them a copy of, any medical report you write about them for employment or insurance purposes before it is sent, unless:

• They have already indicated they do not wish to see it.

• Disclosure would be likely to cause serious harm to the patient or anyone else.

• Disclosure would be likely to reveal information about another person who does not consent.

If a patient refuses consent, or if it is not practicable to obtain their consent, information can still be disclosed if it is required by law or can be justified in the public interest.

When writing a medical report you must:

• Do your best to make sure that it is not false or misleading; you must take reasonable steps to verify the information in the report and must not deliberately leave out any relevant information.

• Complete and send the report without unreasonable delay.

• Restrict the report to areas in which you have direct experience or relevant knowledge.

• Make sure that any opinion you include is balanced and be able to state the facts or assumptions on which it is based.

Payment¹

Who pays for a medical report is an issue which should be established before the report is written. In many cases, this is obvious, being usually the party who requests the medical report (the patient, an official organisation or a commercial company). Fees are sometimes negotiated between the medical profession and the relevant authority⁵ . Some reports are part of the GP's NHS contract but many are not. It is advisable to have an advertised list of fees for the most common reports, so that it is made clear to patients that they will have to pay and how much the medical report will cost.

Doctors are occasionally requested to provide reports for no payment, such as charitable organisations, students seeking evidence of extenuating circumstances for an academic authority or patients requesting support for housing need. As in many other areas of clinical practice, this will require the doctor to make an individual judgement based on the merit of each request.

Presenting information

It is advisable to present the information in as factual a form as possible. Try to avoid making judgements or voicing opinions which are beyond your expertise. If you do not have the knowledge to answer a question (eg, whether the patient is fit for a job with which you are unfamiliar), say so. Most GPs, for example, will not have the expertise of a trained occupational health doctor - the professional the requesting body may need to involve (often at increased cost) if they cannot obtain an opinion otherwise.

Remember also that medical records are not inviolate. They may be inaccurate, incomplete (eg, mislaid hospital reports, visits to alternative practitioners or NHS walk-in centres) or simply not fit for purpose (eg, functional information which GPs may not record). They may be valid from a clinical point of view but not from a legal point of view (eg, accounts of symptoms which had not been personally witnessed by the report writer would be considered hearsay in a court of law). All these points should be taken into account when writing a report.

Conclusion

Reports based on information held by doctors can be useful and valid. However, organisations or individuals sometimes request medical reports based on assumptions that doctors hold more information than they do, to confirm what patients have already told them, or in the mistaken belief that by doing so they can transfer responsibility for the outcome of the report to the medical practitioner. It should be remembered that doctors are not obliged to provide reports outside of their legal and contractual responsibilities. Stick to facts rather than opinions. Do not be afraid to admit you do not have the knowledge to answer a question or to suggest that a person with greater expertise might be better placed to write the medical report, if indeed that is the case.

Before writing a medical report, it may be helpful to consider the following questions:

• What class does the report fall into?

• Has the patient given free and informed consent?

• Who will gain advantage from the report?

• What are the consequences of giving the report as opposed to not giving it?

• How valid is the information on which the report is based?

• Should a fee be required and, if so, who should pay and how much should be charged?

• Is an opinion or judgement being requested rather than factual information and, if so, are you comfortable complying with the requirements?