HL Deb 20 November 1974 vol 354 cc1027-67

3.0 p.m.

LORD REIGATE rose to call attention to the widespread concern as to the continued confidentiality of the reports prepared by hospital social workers and other medical workers in view of the new arrangements imposed under the National Health Service Reorganisation Act; and to move for Papers. The noble Lord said: My Lords, I beg leave to move the Motion standing in my name on the Order Paper. I think it is reasonable to say that there is to-day widespread concern about the invasion of privacy and the absence of confidentiality in many aspects of our modern life. The issue which I am raising is a narrow one affecting the National Health Service only, but none the less I think it is of importance for nowhere, surely, is there more danger to privacy and confidentiality than in the doctor-patient relationship. The noble Lord, Lord Wells-Pestell, will not be surprised at my raising this issue again, as I gave him notice I should do so when I asked a Question in June. But for those of your Lordships who are not familiar with the background to this issue, perhaps I might give a few details.

First of all, under the National Health Service reorganisation the social workers in hospitals, both medical and psychiatric, were transferred to the employment of the local authorities, although remaining at work in the hospitals. May I also explain that these social workers are the heirs of what used to be called almoners. I think, and others think with me, that that was a wrong decision, although I recognise it was taken after fairly considerable thought. But although I think it was wrong, I am not of course seeking in this Motion to reverse that policy or even to argue that it should be changed.

The duties of a social worker are manifold, but they are principally, first, to resettle the patient in the community; and, secondly—and this is the gravamen of what I am raising to-day—theirs is a role of great importance, which is to furnish a doctor with particulars of the social background of the patient whom he is treating. To carry out this latter role, the social worker needs to know a number of certain clinical details of the patient's ailments. To meet the doctor's requirement to know the social background of the patient a full file is built up of details of the family circumstances, as well as of correspondence with local authorities and other outside agencies. It is from this record that the quintessence is extracted for the doctor so that he can know the background of the patient whom he is treating.

There are thus two files. First, there are the clinical notes which include the social particulars, where relevant, which are of course filed with the medical report of the patient. The second file contains the social background and social history notes, including clinical particulars and the correspondence to which I have referred, which have always been filed in the social service department of the hospital concerned. It is with the fate of these latter records that I am concerned.

I must point out that until the reorganisation took place the clinician and social worker were part of a united team. Until then both kinds of files were the property—and I repeat "property"—of the hospital; that is to say, they were the property of the board of governors or of the hospital management committee, as the case might be. No one outside has any right of access, except that I believe that under very exceptional circumstances the Secretary of State has the right to call for those papers; but that right is only rarely exercised. Of course, the doctor and the social worker can, and do, divulge some particulars to others who may be concerned outside the hospital, but they do this only at their discretion, and at their risk as well.

On June 10, I asked a Parliamentary Question seeking an assurance that all these files would remain the property of the health authority and would not be divulged to local authorities without the patient's consent. I received a rather dusty Answer from the noble Lord, Lord Wells-Pestell, but I also had some support from noble Lords on both sides of the House. Perhaps I might summarise the replies that were received. We learned, in the words of the noble Lord, Lord Wells-Pestell, that, Medical case notes about a patient … remain the property of the hospital authority. So far, so good. We also learned that, The custody of social work reports is under the control of the social worker concerned." [OFFICIAL REPORT, 10/6/74; col. 235.]

I ask your Lordships to note the change in the wording. We have "custody" and "control", not "property" and "authority".

If I may answer my own question in simpler terms—which the noble Lord rather jibbed at giving me—the files, including the clinical particulars to which I have referred, are the legal property of the local authority and the social worker can be directed to surrender a file to the local authority. If the noble Lord is in a position to contradict me on that, I shall be interested to hear what he says. But that is the advice which I have received and with which I would agree after reading the Acts concerned. I am sure the noble Lord, Lord Wells-Pestell, believes I am exaggerating the risks that are attendant upon this fact.

I may say that because I was dealing with this matter I thought it right to ask those who have advised me to give some idea of the kinds of particulars which might be involved. I have seen certain records—not actual records, and I have no idea of the source, the hospital or the area concerned; they might, for all I know, be totally fictitious and I do not want to burden the House with any lengthy case histories—and I would be willing to show the kinds of transcripts I have had to any noble Lord who might be sceptical about this issue. I would point out that each file is, or can become, a full social and medical history of a case, or even of a family as well.

In one particular case, of which I have a copy, the husband was a bad heart case; he had angina as well as a coronary. It so happened that the social worker's notes recorded the fact that his daughter aged 15 was pregnant and the mother was very anxious that the husband should not know about this because it was feared that it would affect his condition. The pregnancy was terminated and the girl's father did not know. Later the mother was admitted to the hospital and was a terminal case of cancer. These notes give the sad and sorry history of a family. One particular point that I would make is that no demand was made on any local authority services so that there would be no need at any stage for the local authority to have had the use of that file. If this is typical, I feel that it would not be right to divulge details to anyone outside the clinical team without the patient's consent.

The noble Lord, Lord Wells-Pestell, in replying to my question, seemed to assume that everyone concerned would always act in accordance with the highest professional and ethical standards. I hope he is right, but I think your Lordships will agree that there are always risks. On June 10 the noble Lord, Lord Douglass of Cleveland, in a supplementary question said to the noble Lord: If the noble Lord feels that no professional worker would divulge the information he possesses, what is wrong with making it legal that he should not? To which the noble Lord, Lord Wells-Pestell, replied: It would be a pity if we tried to deal with this matter by some form of legality."— [OFFICIAL REPORT, 10/6/74, col. 237.] To me, my Lords, to say that is to miss the whole point of this discussion and to minimise the risks that there are in this matter. When he comes to reply, it may be that the noble Lord, Lord Wells-Pestell, will quote the Report of the Working Party on Social Work Support for the Health Service published in June and since I last raised this matter. It is a good, thorough, painstaking Report on this subject within its limited remit. It is obviously based almost entirely on experience gained mostly before reorganisation. It does not challenge the changes that were made in the Act but neither does it give an impression of enthusiasm.

I should like to refer in particular to paragraph 18 of that Report from which I will quote selectively but not, I hope, unfairly. That paragraph begins: An important point in this connection is confidentiality". It then goes on: It is a professional issue with implications going well beyond our terms of reference. The paragraph continues: The information on a social worker's file can be quite as sensitive as that in medical and nursing records. It also states: …at no point in our discussions has it been suggested to us that confidentiality presents any real difficulty in working relationships between doctors and social workers provided there is personal confidence between the professionals concerned. I think that that must be seen to relate to the days when the social worker and the doctor were part of one clinical team responsible to each other and to the hospital for which they were working, and not a social worker under the employment of an outside authority. I cannot help but feel that the paragraph in the Working Party's report fully justifies this matter being raised to-day because I think it is clear that I am not alone in my misgivings.

I want to return to this matter of legality and to say why the situation in law needs clarifying. Here I must digress for a moment to remind your Lordships that, apart from other matters, we invented, or rather adopted, the Ombudsman. When this suggestion first came forward I must say that I was not an enthusiast for the proposal, being at that time a Member of another place. I now consider the innovation thoroughly justified, being probably biased by the fact that while a Member of another place I succeeded in getting two cases considered by the Ombudsman who in both cases came down on my side. Now, my Lords, we have the Parliamentary Commis- sioner, the National Health Service Commissioner whose remit does not extend to clinical matters, and, lastly, we have the Local Government Commissioner.

I want to quote from a letter, but before doing so I will recapitulate three points from what I have said: first, the importance of mutual confidence between patient and staff; secondly, the fact that the social workers' notes contain intimate and clinical details; and, thirdly, once again to remind your Lordships that the medical social worker is now employed by the local authority although a member of a clinical team. The letter I wish to quote is from the Director of Social Services of an important local authority and is addressed to all staff including National Health social worker staff. I am told that similar letters are being sent out from other local authorities. The letter reads: All staff who are concerned in any way with the use of files, either on individual cases or general policy matters, must be made aware that a Local Government ' Ombudsman ' can call for any file and that anything recorded thereon is not privileged and cannot be withheld. It is, therefore, essential that although reports and notes on files should correctly reflect the facts and opinions of the officer making the report, they should be phrased in a manner which will not be embarrassing in the event of their being disclosed to outside parties or possibly to the person involved in the case in question. So what, my Lords, becomes of, to quote the Working Party's report: the right of the individual to confidential communication with any professional person with whom they are in contact"? It must mean that the social worker's notes, including clinical particulars, are available to outside parties and possibly to the person involved.

If the instructions in that letter are carried out to the full, it must mean that the social worker's notes will have to be purged of all clinical and personally embarrassing particulars and thereby rendered valueless. That letter could not have been sent out before April 1, because the Local Government Commissioner would not have had any locus standi in the matter. The transfer of medical social workers to local government employment means, as this letter proves, that local authorities now have a legal right of access to information acquired by its employees in the course of clinical duties under the National Health Service. This must be wrong. That, my Lords, is the case I put forward, and I beg to move for Papers.

3.20 p.m.


My Lords, may I thank the noble Lord, Lord Reigate, for raising this issue, because this is, as we know, one which has concerned and disturbed the medical profession of this country ever since the reorganisation of the National Health Service. We have in this country been proud of the agreed code of confidentiality practised by the medical profession and medical social workers within our hospitals, but as yet there is no similar code agreed by social workers working within the community. Therefore, I believe it has been almost impossible to reach an agreement between the two on how to deal with the questions that are now raised by the noble Lord.

I am aware that there have been meetings between the British Medical Association and the British Association of Social Workers, covering a wide range of subjects within the relationship of the two professions and I understand that there is a draft report in front of the BMA. But until the social workers and the British Association of Social Workers can agree among themselves about a code, very little progress can be made between the two professions. On the other hand, like, I am sure, your Lordships, I cannot believe that people engaged in the social services within local authorities are less likely than members of the medical profession to observe the confidentiality of their clients and patients. The majority of them, I am absolutely sure, would abide by exactly the same principles.

The danger in the present situation additional to the ones that the noble Lord brought forward is the enormous turnover of social workers within local authorities, which means that a social worker calling on a family may be followed in the next week by a different one. This increases the danger of passing on the information. The noble Lord referred to the personal confidence that existed in the past between social workers and the medical profession working within a hospital. This is tremendously im- portant and is something which one hopes could be preserved.

I want to raise a point relevant to this discussion, because I believe that what is happening at the moment is militating against this confidence, and I refer to the method of appointment of social workers under the new reorganisation. The workers are appointed by the local authority, and it is possible for the area health authority or the hospital in question to be represented as an observer on the committee appointing a social worker to a particular hospital. But the medical profession and area health authority have absolutely no rights. They are there only as observers and an appointment can be made by a local authority without the agreement of the hospital. It is within my knowledge that some social workers have arrived at a hospital without previously having been seen by the medical profession. They have been appointed and have arrived to do their first day's work. That does not help in building up confidence between the people who are working, one hopes, for the patient in a hospital.

It is a completely different principle that is followed when an area health authority appoints people to work with a local authority. When an area health authority appoints specialists in community medicine to advise the social services department of a local authority, when it appoints child health specialists, when it appoints district community physicians, the local authority is represented on the appropriate committees with full powers, and no appointment would be made which was not acceptable to the local authority. So I would plead that we should have an alteration so that no social worker was appointed without the agreement of the hospital or the area health authority.

3.25 p.m.


My Lords, I have always entertained the greatest respect for the noble Lord, Lord Reigate, because he and I have met on occasions when matters of public health have been discussed. I have always recognised that he has taken a sincere interest in these matters. We have not always agreed, and to-day I have listened to him very carefully and I must confess that I do not think he has proved his case. From what the noble Baroness has just said, one might almost think that this debate to-day is about the professional standing of the social worker in the hospital. Indeed, I have read some material on this question which indicates that there is some ill-feeling, which is absolute news to me, between doctors and social workers. But I understand that what we are discussing to-day is simply the question of confidentiality, and I want to relate what I have to say to this aspect.

I think that the noble Lord's anxiety is misplaced. I believe he has overemphasised something which must have occurred to many people over the years, something which occurs to doctors and everybody in the medical profession; that is, whether any confidence of the patient will be revealed to anybody who may make use of it, which is not in the interests of the patient. If there is this widespread concern, as the noble Lord, Lord Reigate, states in his Motion, why is it not to be found in, for instance, the British Medical Journal over the past few months and years? Since this debate was put down I have checked through my copies of the British Medical Journal, which I take every week and try to read thoroughly, and to my amazement I find that this matter has not even been mentioned by the doctors. I cannot find any complaint in the British Medical Journal which leads me to believe that this matter is causing great concern to doctors or patients.

The media are always feverishly searching for grievances so that these can be ventilated on the radio or television. Has anybody in this House heard of this question being discussed on the media? That is the kind of subject which they would jump at. The commentators would like to have a little heated discussion between doctors, social workers and patients in order to ventilate this matter. But it seems to be unknown to the media. On further inquiry, I found that an article had been written by a Liverpool general practitioner and a social worker. They sent it simultaneously to the journal of the Royal College of General Practitioners and to the journal called Social Work Today. The final paragraph of this very long article dealt with confidentiality and the desirability of exercising vigilance regard- ing a client's affairs. That is the only material on this subject that I can find. Therefore, I think that the noble Lord should be reassured; I feel that he is distressing himself unnecessarily. He should be particularly reassured when he knows that, as a result of this matter being raised in this House—and, sometimes, civil servants may have discussed it in certain places—the British Medical Association, the Royal College of General Practitioners and the Health Visitors Association are to discuss the greater use of shared information, which could no doubt include confidentiality.

I want to introduce an analogous case, because it is concerned with confidentiality. Since the inception of the National Health Service, it has been compulsory for patients' reports to be filed by doctors and, consequently, sent to the right authority. If one bears in mind that a single doctor might be responsible for 2,500 patients, it is inevitable that he seeks help with clerical work. Many of your Lordships know that I am a doctor. I was brought up in the household of a doctor, I have about eight near relations who are doctors, and I therefore know this world. When the hard-pressed doctor seeks help he finds, as everybody knows, that it is difficult to get first-rate secretaries—in the old days (as we call them) a doctor could not afford one, anyway—so he will seek a clerical worker. Often he knows an excellent patient who lives in the neighbourhood and who knows the neighbours well, and he asks her to undertake the writing up of his reports. This is the "norm".

I have never heard a patient objecting to this practice. I have never heard one of the former executive committees which controlled the general practitioner objecting to his finding clerical help of this kind; finding somebody who would examine all these reports and who would know precisely what the family next door was suffering from. Also, I have never seen the medical journals condemn the practice. This is the first time I have ever attended a debate in which such strong exception has been taken to anybody other than a medically qualified person, or a para-medically qualified person, seeing these reports.

We must not suffer under the illusion that people with a medical qualification have a monopoly of integrity. I have heard many doctors reveal confidences, at dinners and so on, which they should never have revealed. But there are people lacking in integrity in many other fields. The fact that a doctor is a good physician or surgeon does not mean he is necessarily always a stable individual. When it comes to his own ego and his own little conceits, he often loves to tell people of the eminent personalities whom he has treated. So I say again that a medical qualification does not mean that the individual possessing it is an individual of the highest integrity.

The average housewife can be relied upon to exercise her discretion concerning a sick neighbour. If the average housewife knows that revealing something about a sick neighbour will not help her, she will certainly respect the confidence. As to this question of confidentiality, when a patient is confined to bed in a house in a crowded road—and, after all, we are talking about all people now, I hope, not only those who live in very select neighbourhoods—and is regularly visited by a doctor and a social worker, her condition cannot be kept secret from the neighbours. I have never had a patient say to me: "I cannot go to that hospital and be in a ward of 20 or 30 beds, because my neighbours will be there and they will know what I am suffering from."

Confidentiality is something which must be seen in proper perspective. I believe the risks which the noble Lord fears are negligible. After all, the one case he quoted—I listened for specific cases—was of a man suffering from some disease, his wife suffering from a malignant condition, and a daughter of 15 who was pregnant and operated on. In the end, the noble Lord had to say that nobody heard about it. The girl was operated on and her condition was not revealed. That was the only case he quoted. The noble Lord must forgive me for saying this, but I know the world of which we are speaking a little better than he does, and I feel that if we are to conduct our social services in an efficient manner in this computerised age, we must exercise common sense.

3.35 p.m.


My Lords, as a general practitioner this problem of confidentiality affects my patients to a great extent and it also affects me; just as it does many other doctors and their helpers in what has been so aptly called "the greater medical profession" which includes medical social works of all kinds. In the short debate on this subject at Question Time on June 10, in this House, the term "professional ethics" was mentioned more than once. It is an important component of what we are discussing this afternoon, and I have been invited to draw your Lordships' attention to some general points about medical ethics which concern us all now. Some translations of the Hippocratic Oath, which is older than the Christian faith, speak about "sacred secrets" between doctor and patient. That Oath has served us well for more than 20 centuries. If someone's son picks up venereal disease, his unmarried daughter has an abortion at the age of 16, or his wife has an attack of depression and attempts suicide, neither the patient nor the doctor, nor the patient's family, wants others to know. Secrets between doctor and patient have in the past been kept; and these have included not only what the patient has told his doctor but what the doctor has found out about his patient. And when a doctor has died, he has often left instructions in his will that all his personal notes should be destroyed immediately. A consultant friend of mine did this only last month.

For a general practitioner, it is still possible to keep the secrets of many patients; but only up to a point. Sometimes, the community also now has to be taken into account. Two examples which concerned me not so very long ago illustrate this: an express-train driver seemed to his family at home to be going off his head—in the end it turned out to be from a slowly-growing cerebral tumour—although he remained perfectly efficient for a considerable time at the routine job of driving his train; and a retired Merchant Navy captain, who for many years has sailed up and down the coast of India, who began later to develop leprosy while living in London. In both cases someone else had to be told, for the safety of others, just as so many other illnesses which may possibly have an adverse effect on the community have to be declared, whether the patient has given his permission for this or not. When I qualified as a doctor I had to swear the Hippocratic Oath, or the greater part of it. Few young doctors are asked to do this now. Had my two medical sons been invited to do so, they say they would have refused because they knew that they could not honour it. As an example of how unrealistic the Hippocratic Oath is at present, one of its sentences reads: I will not use the knife, not even on sufferers from stone". Taken literally that would exclude all surgeons and many general practitioners who do minor surgery.

My Lords, in modern general practice, especially since the introduction of our National Health Service and its reorganisation, with its health centres and large group practices, with so many ancillary services and with the great development of social medicine, this problem is even more important and difficult. Practices vary greatly. In some of them patients see several of the doctors in the group from time to time; their notes and reports are useful to all the partners and also sometimes to others in the team—health visitors, nurses and district nurses, midwives and social workers of all kinds. Many general-practice teams have been growing steadily in size during the past 20 years. "My patient" has become "Our patient", and many members of these clinical teams have acccess, at times, to the medical notes. Some practices insist that all who work in the team sign an undertaking to respect confidential information.

By tradition, necessary medical details which are of importance to a patient's health or wellbeing have sometimes been passed on verbally or in writing from one doctor to another who is in a professional relationship with that patient, with or without the consent, implied or expressed, of that patient or his nearest relative. Sometimes a doctor may have to share his knowledge with a member of another profession—a dentist, chiropodist, physiotherapist, a clergyman or lawyer-—all of whom should agree to be bound by the same ethical rules about confidentiality as those which govern the doctor himself.

When a patient enters hospital still more people are involved—consultants, registrars, house officers, more nurses and secretaries, laboratory and X-ray technicians and highly-skilled and well-educated hospital social workers (who used to be called almoners), psychiatric social workers and others, including, in some hospitals, medical students. They may all see patients' records, or part of them. The main details of a patient's medical record are sometimes put into a computer where, in some respects, confidentiality can be preserved better than in files.

When a patient leaves hospital, a summary of his medical notes is sent to his general practitioner who may find himself, at times, in a good position to coordinate the work of hospital, psychiatric and local authority social workers, perhaps employing the good offices of a community physician, some of whom were called, until recently, Medical Officers of Health.

The rules about confidentiality for hospital personnel are not always carefully kept. Doctors and even lawyers are sometimes at fault. Page 20 of this year's Annual Report of the Medical Defence Union describes how a young woman driving-instructress was teaching a learner-driver when they were hit by a bus from behind. She had been injured and had been treated in eight different hospitals. She was suing the transport company, and the solicitor acting for that company had written to all these hospitals asking them to send him a copy of the patient's records for his perusal. One consultant offered to submit a medical report, another said he would do so for an appropriate fee, and a surgeon at a third hospital did send the solicitor a summary of the patient's notes—all three of them without the patient's permission. The proper procedure, I understand, would have been first to obtain the patient's consent, and then for the medical details to be submitted to medical advisers nominated by her own solicitors.

When a patient moves his home to a new locality a further complete set of medical and para-medical personnel are involved, both in general practice and in hospital. If he happens to move often, his medical notes and reports follow him round each time. How can proper confidentiality be maintained under these conditions? Even if the patient dies, his notes are kept for three years or more before being destroyed; and someone has access to them.

A friend said to me the other day "I loath; the idea of my personal medical notes floating round a health centre or hospital". They do lie around sometimes, and by no means all the cabinets in which they are filed are kept locked. One must be able to trust those with whom one works closely, after impressing on them the importance of strict confidentiality. Even in banks many more people know the state of one's credit balance or overdraft than some of us guess. In a bank any unethical disclosure of information should be the manager's responsibility: he would ultimately be to blame. So with modern medicine; it is the doctors who should be responsible. They have had certain ethical standards for centuries. Under modern conditions, some of these are now inadequate, in spite of the World Medical Association's Declaration of Geneva and, with more practical details, its International Code of Ethics. These are helped in day-to-day practice by the excellent work of the General Medical Council, the Ethical Committee of the British Medical Association, the Royal Colleges, the Medical Defence Union, the Medical Protection Society, and by the recent discussions which have taken place about a possible Code of Ethics for Social Workers between the British Medical Association and the British Association of Social Workers which was founded in 1970.

What is wanted now, I believe, is a review and revision of our own professional ethical code, made necessary by the greatly widened field of modern medical and social care and treatment, and by the special problems for everyone which have arisen from the modern way of life and for parents and their children from the lowering of the age of consent. A general practitioner has, as it were, a foot in both camps—hospitals and social services. The great need now is to close the gap between our medical and social workers, and somehow to introduce the latter properly into group practices for the prevention, early diagnosis and early treatment of social problems which are often so important. This needs continuity of interest between family doctors and the social-worker teams, and increased efficiency without too much duplication of effort. The official attachment of social workers of all kinds to group practices or health centres is helpful, although not essential. Some social workers seem rather remote at the moment; but Chapter 21 of the Seebohm Report says some very sensible things about the ways in which they can be involved in primary medical care.

The ideal is for family doctors to work in teams with social workers whom they know well, in whom they have confidence, and with whom they can safely share their notes. If a doctor has to work with a series of social workers whom he does not know well, one after the other, he is much less likely to want to share with them his notes and his confidential information about patients. On the other hand, information in a social worker's file may be unknown to the doctor and is often quite as confidential as that in a doctor's or nurse's records. I am told that what makes many people unhappy at present is the possibility of copies of the social worker's notes being sent to the local Social Services Department where they may be seen by other people, including the police who may even take action on the information given to them. In a particular case it may be argued that this is in the best interests of society as a whole: but if it happens often it will not be long before patients will be afraid to tell their doctors or social workers about their personal problems.

This question of maintaining adequate medical confidentiality is one of the greatest difficulties we have to face and try to overcome in our conception of modern scientific and community medicine. It is likely, I think, that we shall have to accept as inevitable a widespread sharing of personal medical information, as the price we must pay for efficient community services. But some patients and doctors will never be altogether happy about this. If a judge, in court, orders a doctor or social worker to disclose information which would break a patient's confidence, and he or she refuses, that doctor or social worker is liable to be committed to prison for contempt of court.

It is a pity, I think, and sometimes unnecessary, for patients' indiscretions to be recorded in their medical notes, for so many eyes to see, for the rest of their lives. If confidentiality cannot be considerably tightened up, it would be reasonable, I believe, for some method to be devised for erasing details which patients do not want to appear on their permanent records. The recently passed Rehabilitation of Offenders Act affords convicts protection against disclosure of their criminal records. Surely patients should have similar protection against disclosure of shameful details relating to their past medical histories. On the other hand it has been pointed out that, sometimes, these details may be helpful later in deciding on a patient's proper care or treatment; for instance, with a young man going up to university, a previous attempt at suicide should be made known, with his permission, to his college doctor. Details of a patient's past medical story may be useful, occasionally, for medical or social research. His name would come to light during the course of the work, but it need not be published. These details may sometimes be important too, for historical reasons; but how soon after the patient's death they should be revealed is a matter for debate. One famous consulting physician suggested to me just before he died that his notes might perhaps be put into a museum, so that future generations could see what kind of medicine we practised in the middle of the 20th century. The Royal College of Physicians has them now.

However. I myself believe that a patient's wishes and feelings should in many cases be paramount; and that after a lapse of time, if he is concerned about confidentiality, he should be allowed to ask for the removal from his records of any details of which he is worried or ashamed, and to which he does not want others to have access indefinitely. If this proves impossible it is likely that many patients will refuse to disclose important personal information, particularly when they live in small communities where most people know everyone else. Often, at the patient's request even now, the doctor or social worker, or whoever it is who talks to the patient, does not put down in his notes full details of personal matters which have been discussed. This ensures what the noble Lord, Lord George-Brown, put so concisely on June 10—the "protection of a patient's personal privacy". The interviewer may even keep a secret file of his own which he seals up. Some psychiatrists make their notes in two parts; one solely for their own personal use, while the other, filleted, version can be seen by any who wish to do so.

No one is perfect. It is very rare to find a completely stable person with no undue worries, who has never done anything of which he is ashamed, and who has no neurotic traits of any kind. Shakespeare wrote in Measure for Measure, Act v, scene 1: They say best men are moulded out of faults, and, for the most, become much more the better for being a little bad". Confucius said Our greatest glory is not in never failing but in rising every time we fall". Many of us have private worries which are as often physical as psychological. Only one person can be in really very close personal, almost confessional, touch with a patient at any one time, to help him gain insight into a difficult situation. Once a patient unburdens himself to a confidant, which in itself often requires a considerable amount of moral courage, he does not want to repeat the story all over again to someone else, or for it all to be put down on his records for others to read for years to come.

A person in trouble wants to find an unshockable and unshakeable ally in his doctor, his social worker, a friend or in his padre; someone who will not moralise or judge him, in whose counsel and sympathy he firmly believes, who will back him to the utmost, and not divulge a single word to anyone else without his i knowledge and consent. That is the kind of personal help, my Lords, which so many people want and which they have had in the past. Our problem now is how best to combine this with the splendid community services which have been so greatly developed in this country during the past 30 years, and how we can bring our ethical code up to date so as to include everyone who works in our greater medical profession.

3.55 p.m.


My Lords, I should like to start by thanking the noble Lord, Lord Reigate, for introducing this question of confidentiality which, despite what some speakers had to say, is, I think, an extremely serious issue. It is, of course, serious, as we know, and as the noble Lord, Lord Hunt of Fawley, was saying in one way and another, because once it begins to be doubted then you have lost a patient's confidence and he will no longer come to you, whether you are the doctor or the social worker, to give you all the knowledge of his case which you ought to have. I often think that the confidences told and exposed to the social worker are more sensitive than the ones exposed to the doctor. It is not usually a matter of great social implication that somebody has gone into hospital temporarily for a heart attack, or something like that, but it has very much greater implication if a woman says to the social worker that the children are not being properly fed because her husband comes home drunk every night. That is the kind of information which a social worker is more likely to have than a doctor.

I was not quite sure that I understood all the implications of the speech made by the noble Baroness, Lady Summerskill, who seems to wish to assure us—and I think with reason—that breaches of confidence are rare. Nevertheless, she seems to have complete faith in the neighbours as to not giving away confidences (faith which I would myself doubt), but little faith in the doctors, especially at dinner parties. But whatever the message was I think the essential point is that there is all the difference in the world between records which are confidential and known to be confidential—which are in the care of one, or possibly more than one, person who knows that they are confidential and who normally will not reveal them unless there is a very good reason for doing so—and the situation where somebody has a right to inspect a record. That is the new situation.

I thought that the extract which the noble Lord, Lord Reigate, read to us was really absolutely shocking and I feel sure that this House ought to try to ensure that that kind of situation does not occur, and if this means a "National Health Service Reorganisation Reorganisation Act", well, my Lords, let us have it and put these things right. I do not want to speak for very long because there are other speakers and I must make an apology that I have at 4 o'clock a Committee of this House which I really ought to attend. So, with your permission, I will not stay till the end. I will just give an example from my own experience. Our records at the Manchester Royal Infirmary and other hospitals at which I have worked for a long time were never revealed with- out the permission of a patient. If the records officer received a letter asking whether somebody could have a copy or a sight of records of such and such a person, and it was a patient who had been in my unit, the records officer would ask me about it but would first inquire whether the patient's permission had been given. The patient's permission had to be given in writing, otherwise we would never reveal any of our records.

One day I received a letter from a Medical Officer of Health of a local authority near to Manchester, stating that a certain person had applied for a job with the local authority; he understood that he had been a patient of mine and would I, as one doctor to another, kindly tell him for what reason the patient had been in hospital and whether this would in any way affect the patient as being suitable or unsuitable for work as a gardener in the public parks. I wrote back, greatly, I am sure, to this man's surprise, to say, "If you were a doctor who was to take over the treatment of this man who had now moved to another district, and I had his permission to reveal his case notes to you, I would be only too glad to do so, but you are clearly acting for an employer. In that sense you are not a doctor at all." I made this quite clear in my letter. I received a letter from this man to say, "I need not trouble you, because your surgical colleague has revealed it all to me". I do not know what lesson one learns from that, but one can learn, at least, that such situations occur because many doctors are not really careful enough about revealing details in case notes. I hope that we will go on pressing; I think probably the noble Lord, Lord Reigate, will.


My Lords, before the noble Lord sits down, may I ask him whether he would reconsider his decision and perhaps try to remain in the Chamber to the end of the debate. We should try to encourage people who have spoken in the debates to listen to the reply of the Government. I suggest that the proceedings of the House are more important than a Committee of the House, of which I am also a Member.


My Lords, I am very pleased to take that advice.

4.2 p.m.


My Lords, I also am very grateful indeed to the noble Lord, Lord Reigate, for raising this important subject. I wonder whether the time has not come when we should take a new look at the decision arrived at some time ago to remove from the National Health Service the statutory responsibility for the social and the psycho-social care of sick people. Before the establishment of the Social Service Department and the reorganisation of the Health Service, medical social workers and psychiatric social workers were members of what one might call the clinical team looking after the patient in hospital and there was really no question at all of any breach of confidentiality occurring. Now, that situation has rather changed, partly because of the extraordinary situation that social workers in the National Health Service are not paid as much as those working for the local authority. But that is a minor point.

I think we are all agreed that for the needs of the patient to be fully understood, it is clearly right that the medical and social information about him shall be shared so far as is necessary between those who are sharing the task of caring for him. I do not think anyone would have any objection to that. But one wonders whether it is right and proper that medical information about patients should be equally available when their needs can be no concern of the local authority.

The noble Lord, Lord Reigate, referred to the report of the Working Party of the Department of Health and Social Security, Social Work Support for the Health Service. This Report makes this rather curious remark in paragraph 31, which says: This responsibility of the social workers in the clinical team is not incompatible with accountability in other respects of the local authority social service department". That raises the question in quite a big way of who owns the record of social workers in the Health Service. I am referring to the social record, and not to the social report which can be attached to the medical case notes. It is very important to get the answer to the question: who owns the records held by the social work department? Where they deal with medical people, is the owner the local authority? This leads to another question: who should decide which social workers, apart from those working in a clinical setting, will have access to cards and files containing medical information about patients? Most hospital social workers deal with medical rehabilitation, convalescence, terminal care, aftercare, and quite a number of things which are very important to the patient. These matters do not need to be referred to the local authority social care committee. But the question is: does the Area Hospital Authority or the local authority hold overall responsibility for the social worker's role in this respect?

I have been talking in a rather melancholy and foreboding way, but I got a little encouragement when I made some inquiries from the hospital where I used to work about their connection with the Social Service Department. They told me that when the Social Service Department first came in, there was very grave anxiety about the confidentiality of material that might be available. There was a series of meetings with the local authority. It would seem that some of that anxiety has been lessened now because the Social Service Department have assured the hospital that they fully appreciate the need to safeguard the privacy of their clients. I may say in passing that this local authority is the London Borough of Camden, which is well known for the good work it does. This borough has always worked on extremely good terms with the hospital to which I referred. But I still think anxiety is there. I was very pleased when the noble Baroness, Lady Summerskill (I think it was) said that there are talks going on between the BMA and the British Association of Social Workers. In the long run, that can do nothing but good.

It is said that one should get the permission of the patient before passing on information. That again is a very good thing to do if it is possible, but unfortunately it is not always practical, for a variety of reasons with which I will not bother your Lordships at this late hour. What I can say is that if one has a good relationship between the medical profession and the Health Service, and if there is a reasonable amount of respect for the others, it may be possible to find some way of avoiding the enormous difficulties one can see in the question of confidentiality.

A medical social worker wrote to me about this debate, and I will conclude by repeating what she said. She hoped that we would be able to confine the debate to the dilemma resulting from inappropriate structure following statutory provision, and not drift into recrimination about poor liaison, co-operation and communication. If we can avoid that we might get somewhere, and that is what I trust we shall do in this short debate which has been initiated by the noble Lord, Lord Reigate.

4.11 p.m.


My Lords, I advance like Daniel into the lion's den following, as I do, no less than four doctors. But I am encouraged by the noble Lord, Lord Hunt of Fawley, to emphasise that I am one of the most important people here because I happen to be a patient from time to time, and that is what we are really talking about. My starting point is about two years ago when the King's Fund mounted a conference about the reorganisation of the National Health Service, and the duty that would lie on the doctors and social workers to co-operate. To my astonishment and dismay, when the conference was opened for debate, one doctor after another got up and said that nothing would induce him—I say "him", not "her"—to give to a social worker the information that he had about his patients. I think it was perhaps understandable at the time. I hope that this concept is now changing in the integrated Service.

If we can consider it from the administrative point of view, the old-time almoner—and what a delightful word "almoner" is—has now become the social worker, who often has a degree in social science and probably has a diploma in social case work. In this change of status he or she, the social worker, is still accountable to the Director of Social Services of the local authority, but—and this is the point which I should like to emphasise—is not really accountable to any national body. I feel that there should be set up a general medical social workers council to match up with the General Medical Council and the General Nursing Council. Then each of these three bodies could work hard to correlate this question of ethical standards. One imagines that the social workers would appreciate such a council, particularly the psychiatric social worker who is often in a most difficult position. If such a council was established by Statute it would have to work out for itself the registrable qualifications for the social workers and be responsible for its ethical standards. One imagines that such a council would go a long way to meet the doctors' fears, if fears there be to-day, that there may be problems on this question of confidentiality.

It has been said that, "Change is the process by which the future invades our lives". The integrated Health Service is not only a change, but reflects a general awareness of social responsibility. I am amazed at the contrast that there is in the Hippocratic oath and the Soviet doctors' oath. Let me try to illustrate the problem by an incident in the Midlands some 10 years ago. There, near a psychiatric hospital, a young lady was murdered in most distressing circumstances. It was quite clear that none of the patients in the hospital could have been concerned. But the police came to that hospital and, having first established this point, they then asked for permission to interview previous patients, patients discharged from that psychiatric hospital who might have been living in the neighbourhood.

I do not know what Members of your Lordships' House might have done; I think the right answer was given, and they gave this information. I may say that the results were unfortunate in some ways, because police cars were going to houses of men and women who were thought by their neighbours to be both medically and mentally healthy, in order to carry out these investigations. That is the point to which several of your Lordships have referred; this question of confidentiality about the individual and the responsibility that there is to the public at large.

There seem to be some variations in the translations of the Hippocratic oath, but one paragraph reads: Whatever in connection with my professional practice, or not in connection with it, I see or hear in the life of men which ought not to be spoken of abroad, I will not divulge as reckoning that all such should be kept secret. I hope I will not be accused of being a communist, although your Lordships can accuse me, if you like, of trailing my coat. But what a contrast there is between that, to my mind, outmoded oath and the oath taken by the 30,000 doctors who graduated in 1971 in the Soviet medical schools.

I will read only two paragraphs. The first is: To devote all my knowledge and strength to the protection and improvement of the health of man, to the treatment and prevention of disease, and to work conscientiously wherever the interests of society require it. Then, although there is a reference to medical secrecy, it ends: To cherish and develop the noble traditions of domestic medicine, to be guided in all my actions by the principles of communist morality, to remember always the noble mission of the Soviet doctor and his responsibility to the people and the Soviet State. One can argue whether that is an oath that in British terms British doctors would be prepared to take. But it certainly reflects a change in emphasis on this question of confidentiality.

I do not know whether I should apologise to the noble Lord, Lord Reigate. He initiated this debate, which has given us the opportunity of having quite a wide-ranging discussion on confidentiality as a whole. My two points are, first, that we might consider setting up this council, with all that that implies, specifying the duties and responsibilities of medical social workers and making them akin to that of doctors and nurses. Secondly, in our new integrated Health Service, we should ensure that there is a more general awareness among all the senior personnel of the hospitals and in the social services of the obligations that we owe as a team both to the individuals and also to society.


My Lords, before the noble Lord sits down, I wonder whether he could amplify one point on this very interesting suggestion about a council for social workers. Is that only for medical social workers or for social workers generally, and if the former will it cover medical social workers not only in the hospitals but in general practice as well?


My Lords, my thoughts were for medical social workers only, and I agree that it would be all-embracing within that context.

4.17 p.m.


My Lords, I quote: Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one. This as your Lordships have already heard, is an extract from the Hippocratic Oath. Confidentiality is a subject which has been given much attention over the last two or three years by the British Association of Social Workers, among others. Just as much confidential material comes to a social worker, whether based in a hospital or in the local authority, as i information, which is equally confidential, which comes to a doctor or other staff in a social services department. It is true that the question of confidentiality in the early stages of the reorganisation of the National Health Service, and particularly the much debated question of the transfer of social workers from the Health Service to local authorities, was the topic on which many frustrations and anxieties were both legitimately and illegitimately focused. But this concern now seems to have become more of a professional interest in seeing that information is used appropriately, and that the principles of when and when not to share information should be clearly understood by all concerned.

The chief means by which a social worker's service becomes available is through the relationship established between the worker in an agency and the client. Within this relationship the client gives, and is enabled to give, information about himself and his family which is of a highly personal and emotionally charged nature. It is a basic principle of social work that such information must remain confidential and that the social worker has a duty to safeguard the confidentiality. The client must have the assurance that information which he has shared within a relationship of trust, as part of the process of receiving help from the agency, will not be disclosed unless he agrees to the disclosure. If this confidence is betrayed, the relationship between the client and the social worker may be damaged and the service which the agency offers thus destroyed.

The client's right to confidentiality is, therefore, of the highest importance. It cannot, however, always be seen as an absolute right. There are times when the rights of the individual client are in conflict with another individual or with the rights and concerns of the community as a whole. On these occasions, the social worker has a duty to establish the justification for the right of the client to confidentiality being superseded by another and greater right. Written material, too, is susceptible to misuse and can lead to a breach of confidence.

It is, therefore, essential that agencies should define their reasons for making social work records and should establish an appropriate policy for safeguarding confidentiality for their clients. Issues such as access to records and communication with administrative departments should be regularly reviewed. However, the establishment of study and research on the subject of confidentiality within the field of social work should not be pursued in isolation, but should be related to developments in the older professions in order that a comprehensive code of practice may be established to the benefit of all concerned.

My Lords, I should have been at a Select Committee of this House at four o'clock but, as the noble Lord, Lord Aberdare, has pointed out that the proceedings here take precedence over a Committee, I shall wait for the winding-up speech.

4.23 p.m.


My Lords, I am grateful that the noble Countess is to listen to the end of the debate. We shall very much value her presence, as we have valued her speech. I should like to congratulate my noble friend Lord Reigate on having put down this Motion for debate. It is a Motion of immense importance, and one very well suited to a mini-debate of this kind. I do not think that many of your Lordships who have spoken in the debate will have agreed with the noble Baroness, Lady Summerskill, that this is not an important subject. However, I am sure that she is, at any rate, not unused to being in a minority in her views, and she will not change them as a result of anything that I might say. Certainly the debate brought forth a number of extremely interesting speeches, and if I might single out just one it was that of my noble friend Lord Hunt of Fawley who gave us from his own highly practical experience as a doctor some of the very real prob- lems of confidentiality which arise for a doctor.

There was one other point, made by the noble Baroness, Lady Robson of Kidding-ton, with which I found myself in considerable agreement. If the National Health Service, on its appointment boards by which a person is appointed to take part in local authority activities, has a local authority representative with a voice, on the reverse side of the coin, when a local authority is making an appointment for a person who is to work within the National Health Service, it should be right for the National Health Service to have a representative on that appointment board.

The Motion in my noble friend's name is narrowly drawn, and refers to that aspect of confidentiality which has been affected by the National Health Service Reorganisation Act and the unification of the social work profession. But this is really only one aspect of a problem that has arisen as a result of the increasing role of the community social services in the division of general health care. We have all been aware over recent years of the increasing importance which has been given to the need for preventive community services, and for minimum stay in hospitals. Time and again in debates in this House people have said how important it is that we should use our expensive facilities—and the hospital bed is about the most expensive we have—as sparingly as possible, and that we should increase the provision of social support both to prevent patients having to enter hospital and to give them the support that they need so that they can leave hospital at the earliest possible moment. This is clearly not only of financial advantage but also of benefit to the person himself.

The practical effect of this has been to expand enormously the social work provision and the numbers of people in the social work profession. The Seebohm Report brought the Social Service Department into being, with its Director of Social Services, and with its Department made up of the so-called generic social worker, each ideally able to give support to a family or an individual in social need, whatever that need may be.

So far as the National Health Service is concerned this situation has had two principal effects. In the first place, it has resulted within the hospital in the merg ing of the medical social worker into the main body of the profession, and this is the point to which my noble friend Lord Reigate draws attention in this debate. Secondly, in the general practitioner services, it has resulted in the attachment of social workers—together with nurses, health visitors and midwives—to group practices, as was mentioned by my noble friend Lord Hunt of Fawley. It seems to me that these policies of greater involvement of the social worker in the medical field, in co-operation with the doctors and the nurses, is right in principle, but it raises the problem of confidentiality in respect of the patient's records, which we have been debating this afternoon.

The difficulty is quite obvious: if the doctor, or social worker, maintains complete confidentiality, then it may be that the others who are working in the team with him are less well able to help the family or the individual. If, on the other hand, the doctor, or the social worker, is too free in giving access to his records, then it may well be that matters which the patient considers confidential when he told the doctor may come to be known more widely, and this will be to the detriment of good patient doctor, or individual social worker relationships. It is clearly right that we should debate these questions, and that we should try to find some way of improving the present situation that has arisen as a result of the increase in the importance of the social work profession.

Your Lordships will remember that there was a report on privacy, by a committee under the chairmanship of Mr. Kenneth Younger which reported in July 1972, and this committee just touched on the matter of medical confidentiality in paragraph 381 of the report. It concluded that legislation would not help in this sphere. In general, I find myself in complete agreement with that conclusion. I concede to my noble friend Lord Reigate, who was supported by the noble Lord, Lord Amulree, the point that there may be legal questions such as the ownership of social work records within the National Health Service. That is a point which I hope the noble Lord, Lord Wells-Pestell, will be able to deal with; but in general, in trying to achieve future arrangements for ensuring confidentiality of records, I do not believe that this function is the role of legislation.

The Younger Committee thought that the answer lay basically in professional ethics, and that the medical profession should examine the problem and make its own code of practice for doctors. But since then the matter has gone rather wider. The general tenor emerging from this debate is that it is not only the medical profession which should apply its mind urgently to this matter, but also the social work profession—and the two of them together, ideally. I hope, therefore, that as a result of this interesting debate the Government will be able to try to move things along a little more quickly in this sphere, in trying to urge on the professions that it is up to them to try to establish a code of practice which will guide the future actions of the medical, nursing and social work professions. I am sure that this is a most important and urgent task. I hope that when he replies the noble Lord will be able to give us some encouragement to ensure that the initiatives of my noble friend will be helped along.

4.32 p.m.


My Lords, the debate this afternoon has a special significance for me, because I am a professionally qualified social worker who spent—I confess many years ago—some years in the London Probation Service, and who was subsequently a tutor and a lecturer on training courses for social workers, both professional and voluntary. So I have listened with great interest to all that has been said about the confidentiality of reports prepared by hospital workers, and of those to which they have access.

This is no new matter. It is something which has exercised the minds not only of professional social workers, but of voluntary social workers over many years. I do not take issue with any noble Lord or Lady who has spoken in the debate this afternoon. I recognise the anxiety expressed and if I take exception at all to anything that is said it is to the underlying—I put it no higher than that—implication that local authority social workers have a different standard of ethics. They have not. My noble friend Lady Summerskill raised the question of whether there is widespread concern. I do not know how widespread it is, but I do not think it is widespread in the sense that we tend to use the word in everyday speech, any more than I think that there is a concern about it other than an anxiety.

I do not want to try to answer every noble Lord who has spoken, but the noble Lord, Lord Aberdare, suggested that the hospital ought to be represented on the committee appointing social workers who are to work in hospitals. With great respect I do not think that this point will arise, for the present medical social workers who are employed in the hospital setting cannot be taken away from that setting unless they wish to leave it.


My Lords, it was the noble Baroness, Lady Robson of Kiddington, who put that suggestion forward. I would imagine that although it is perfectly true what the noble Lord said, that there must in future be such appointments, as the noble Baroness has practical experience as a chairman of a regional health authority I believe that she was speaking from her experience. I was supporting her view.


My Lords, I understand the situation. In the future there will not be such appointments: vacancies occurring in the hospital set-up will be replaced as they occur by the local authority from the existing local social workers. One would assume that they would take some care to see that the right type of people were appointed. I think it was the noble Lord, Lord Aberdare, who raised the question of the custody of medical records in the National Health Service. Perhaps I could say this—


It was the noble Lord, Lord Reigate.


I thought that the noble Lord, Lord Aberdare, also referred to it. But medical records in the National Health Service, whether kept by general practitioners or hospital doctors, are generally held to be the property of the Secretary of State. This point has been confirmed by the courts in Scotland, but it has not arisen in England, so there is no decision of the judiciary.


My Lords, if the noble Lord, Lord Wells-Pestell, will allow me, this is the crux of my whole speech and the crux of the matter based on his reply to my Question on June 10. No-one is denying that the medical records are the property of the Secretary of State. What I am talking about is who owns the files that the social worker compiles? I am sure that the noble Lord, Lord Hunt of Fawley, and the noble Lord, Lord Platt, understand the difference. They, as understand it—and I am advised on this matter too—say that as this work is being executed by the social workers, who are now local government employees, such files are the property of the local authorities. That is the point that I wanted to underline.


My Lords, will the noble Lord allow me to return to this matter because I have spent some time on the subject—several hours in the light of the discussion we had earlier on—and I have, I hope, got certain things in some kind of order? As I explained when replying on June 10 to a Question by the noble Lord, Lord Reigate, although hospital social workers are now employed by local social service authorities, the custody of social work reports is under the control of the social worker concerned and the disclosure of their contents is a matter of professional ethics for the social worker in consultation, in appropriate cases, with other members of the clinical team.

The nature of social work requires that social workers must command the confidence of their clients. It is, therefore, essential to the social worker, as to the client, that information received in confidence should not be disclosed without the client's agreement. But there may well be occasions when someone returning to the community after a stay in hospital may need help and support from a social worker in the community care field, and for the proper continuing care of the patient the second social worker surely must be made aware of the special needs and problems which have been discovered in the hospital situation.

In these circumstances the hospital social worker—I would hope—would seek the patient's agreement in passing on these necessary details. Noble Lords may be fully assured that social workers outside the hospitals are as conscious as those within hospitals of the high standard of professional ethics required of them. Social workers involved in the life of the community are well accustomed to receiving information which is a matter of strict confidence, and they may find themselves having to ask a client for agreement to disclose confidential matters to, for example, if I may give one, the general practitioner who is also going to look after that person, and help them with that person when he or she returns to the community.

I think we must keep it in the forefront of our minds (I shall probably not express this too well, but I hope I will not be misunderstood) that doctors and social workers are concerned with different areas of human functioning. Naturally, doctors will concentrate on the health and sickness of their patients: social workers are likely to lay more emphasis on relationships within the family, the community, society as a whole. If the doctor and the social worker between them are going to produce and return to the community a whole person, surely they have got to work together; surely there must be a disclosure between them of what one knows and what the other knows, so that the continuing care that is necessary can be carried on when the patient rejoins the community.

My Lords, I hope that we would all agree that the welfare of the patient or client (I use those two terms to denote medical and lay) and, where appropriate, of his family, must be the first concern of those responsible for treatment and support. To this end collaboration and co-operation among social workers, doctors and other Health Service workers, both in and out of hospital, is not only essential but must be a continuing thing. All these workers will have need of each other in promoting the best interests of the patient or client; and it must, I suggest, be left to their professional discretion, after consultation with the patient, to decide what kind of information must be exchanged between the two, the social worker and the doctor.


My Lords, may I ask the noble Lord, with great respect, which of the speakers doubted any of these things? I do not recognise that anybody did doubt those things.


My Lords, is my noble friend aware that many of us welcome what he is saying because this kind of background is very helpful?


My Lords, clearly underlying the speeches of one or two noble Lords there was the fact that it would be very difficult to maintain confidentiality if information had to be passed on to the social worker. If I have said something that to certain noble Lords appears unnecessary, I think it is sometimes necessary to state these things so that there is no misunderstanding.


My Lords, may I interrupt the noble Lord? I have the feeling that the sentiments which the noble Lord has expressed are generally acceptable, but I am not sure that they completely allay the anxieties which were raised at least in my breast as I listened, as a complete amateur, to the unfolding of the subject. The noble Lord, Lord Platt, told us of an extremely interesting episode concerning a request made to him in regard to someone who had been under his care—an improper request which he naturally refused. The question that I should like to ask is this. Without in any sense disparaging social work or social workers, is the ethos prevailing in that branch similar to the ethos which, so to speak, automatically governed the doctor in the position of the noble Lord, Lord Platt, in the story which he told us?


My Lords, T have neither seen nor heard any evidence, either to-day or at any other time, that leads me to believe that professional social workers have a lower standard of ethics than members of the medical profession. If I could leave it there, perhaps it would be wise for me to do so.

The noble Lord, Lord Reigate, quoted from the Report of the Working Party on Social Work Support for the Health Service. I intended to quote precisely the same section of that Report as he did, but I should like to make this one difference. The part which the noble Lord quoted related to post-April 1, 1974, and not pre-April 1, 1974. I want to quote, as did the noble Lord also quote, this part. The Working Party on Social Work Support for the Health Service said: But we can record as a matter for encouragement the fact that at no point in our discussions has it been suggested to us that confidentiality presents any real difficulty in working relationships between doctors and social workers provided there is personal confidence between the professionals concerned. The Report goes on to say: For the needs of the patient to be fully understood, however, it is clearly right that medical and social information about him should be shared as far as necessary between those who are sharing in the task of caring for him. This will mean an exchange of information. It must be and is clearly understood by both sides (and I am sorry we have to divide this up into two sides) that there must be confidence. If I may revert to the Probation Service, has anybody heard of any breach of faith in the Probation Service? That Service has been going for years, and there are very few people in the community who acquire possession of more confidential information than probation officers, yet there has been no breach.

We are in danger of anticipating difficulty when it is not likely to occur. I should perhaps make the point that the Working Party included a substantial representation of both doctors and hospital social workers, and that in this recommendation, as in all others, they were unanimous. In using the words, as they did, "as far as necessary", the Working Party clearly took the view that the decision as to what ought to be disclosed should be a matter for professional judgment, and that there should be no question of unrestricted access to records or unreasonable demands for information on either side.

Now the question of responsibility for hospital social work records since April 1 is another point on which a great deal of concern has been expressed. I will try to clarify the situation. Before April 1, hospital social workers were employed by the Health Service, and reports prepared by them before that date were and remain the property of the Health Authority. Since April 1, hospital social workers have been employed—many of them against their will, I know—by local authorities, and reports prepared after that date are the property of the local authority. But let me make it quite clear that medical case notes about a patient, including any contribution made to those notes by a person who is not employed by the Health Service, remain the property of the health authority.

Lastly, hospital-based social workers, as members of hospital teams, may find themselves from time to time contributing to the team knowledge of a patient rele vant to his treatment. This knowledge would be confidential to the hospital team. I really do not see what more—certainly not at this stage, for it is only November—can be done to protect and safeguard the interests of the patient or client or, for that matter, the position of the doctor or social worker. I think that the first general point to make is that the use of information about a client is a matter of professional ethics and common sense, rather than of legal ownership. It is a matter for close consultation between all who are professionally concerned with the care and treatment of the individual. A suggestion had been made that there should be a legal requirement that a professional worker should not divulge confidential information obtained in the performance of his work without the consent of the patient.

I think that this suggestion arises because some doctors and social workers fear that, without such a requirement, social workers who are employed by local authorities could either themselves make irresponsible use of information about patients, or be constrained by their employers to divulge it in circumstances which would be harmful and damaging to the patients' interests. However, these fears, I am quite convinced, are baseless. Ever since I saw this Motion down on the Order Paper I have been at some pains to discuss this matter with certain doctors I know, with social workers and even with medical social workers. I recognise the fear and the anxiety, but I think that we should be able to distinguish between a feeling of anxiety and the fact that something may happen or has happened. Social workers employed by a local authority have their professional integrity like other professional people elsewhere and this would absolutely forbid them to act in either of these ways. Of this I am quite sure. Moreover, local authorities require a high standard of integrity in all their staff.

I do not think that we have any grounds for regarding social workers as less responsible than other professional workers or anyone else entrusted with private and confidential information. Local authority social workers come into possession of an enormous amount of confidential information, as do probation officers, to whom I have made reference. There is no evidence and no reason to believe that there has been any real abuse. We heard of one incident this afternoon and I am sure that if some of the noble Lords who have spoken could have given chapter and verse of abuses they would have done so, and quite rightly so.

This means, for example, that in the event of a local councillor asking for personal reasons to see the case papers of a client of the Social Services Department, the social worker concerned would quite rightly refuse. This would apply whether or not the case papers included confidential medical material. If, in order to decide the appropriate local authority action on a matter before them, councillors needed information about a person, it would be a matter for the chief officers of the authority, in consultation as appropriate with any doctor—whether a general practitioner or a hospital doctor—concerned in the case, so that the authority might have such advice as was appropriate in the circumstances while confidentiality on all aspects was preserved where professionally desirable.

My Lords, I may add that this is not a problem peculiar to the local authority world or to the personal social services. It is one which will undoubtedly appear in the Health Service setting. As I told your Lordships' House in the debate in June, discussions have been held between the British Medical Association and the British Association of Social Workers about the circumstances in which information about a patient or client should be disclosed to members of other professions. There have also been discussions about confidentiality between the Royal College of General Practitioners and the British Association of Social Workers and, as my noble friend Baroness Summerskill said, there appeared yesterday in Social Work a long article on the subject which was published simultaneously in the Journal of the Royal College of General Practitioners. Regular discussions between social workers (both hospital and local authority based) at local level and with members of other professions have shown—these have taken place in a number of areas in England—that anxieties over the exchange of information can be resolved, especially when the importance of this matter is recognised in ensuring good service for clients. These matters should be settled by understanding and agreement between practitioners rather than by Parliamentary or Government intervention which could result only, I believe, in the creation of a rigid system of rules which in the long run would tend to work against the interests of the patient or client.

My Lords, I hope that, while recognising the anxiety and the fears, we also recognise that this is no new situation. It is a situation which other professional organisations, both voluntary and statutory—and I did refer to the Probation Service—have had to face over a number of years. I hope that we can keep in the forefront of our minds that the important point is to do as much as we can for the individual when he or she leaves the hospital setting and returns to the community, where he or she may need continuous and continuing supportive help from a local authority social worker. I hope we shall bear in mind that it is necessary for the two different settings to come together from time to time to discuss the progress made and to exchange information. In the last analysis, I am sure that everyone in your Lordships House is concerned only to do what is right for the individual and, ultimately, for society. I think we can do this only if we keep in the forefront of our minds what the noble Lord, Lord Reigate, has said. I am glad he raised this matter

I think it is right and proper that he should have aired this matter much more fully than he was able to do on a previous occasion but, having said that, I hope we shall recognise that the discussions now taking place between the British Association of Social Workers, the British Medical Association and the Royal College of Medical Practitioners will take time. Out of these discussions may arise some recognised code of ethics—I do not know; but let the discussions go on, and let us not hamper them with our fears and anxieties.

5.0 p.m.


My Lords, I think I have the right, if not to reply, at least to make some comments on what has been said. First of all, may I thank all noble Lords who have taken part in this debate. I thank those who have supported me in my anxieties, and I am tempted to thank also the noble Baroness, Lady Summerskill, because although she disagreed with what I had to say I think she helped to bring out the ire and fervour in the noble Lord, Lord Platt, and other noble Lords who have some anxieties. The noble Baroness said I had not proved my case. I was not trying to do so. She also said that I was wrong in saying there was widespread concern, because the matter had not been mentioned in the British Medical Journal or on the media. I do not read the British Medical Journal and I cannot think that is necessarily the only standard by which we should judge widespread concern. I was of course referring to widespread concern inside the National Health Service, and I should have thought that was obvious from the wording of the Motion. As for the noble Baroness's own reminiscences of the postprandial indiscretions of some of her doctor friends, the less said about that the better. I have never spoken with any social workers in this way or accused them of any similar kind of indiscretion—and I am going to have a word with my own doctor to see that he does not make that kind of remark about me after dinner, thank you very much!


My Lords, may I say that the noble Lord, Lord Platt, reminded me of the fact that his own surgeon had betrayed him.


My Lords, I am very grateful. I was particularly interested in the rather wider issues introduced by my noble friend Lord Hunt of Fawley, and I look forward to reading his speech. I am a mere layman and can speak from only very limited experience, but I assure your Lordships that widespread concern still exists. I was most interested in the suggestion put forward by the noble Lord, Lord Hayter. I interrupted him to ask whether he was referring to medical social workers or to social workers, because this would be an admirable suggestion. The difficulty arises with the medical social worker who comes straight out of local authority service and is generically trained. Would he be eligible for his Social Workers Council? This, if I may say so, is a "re-hash" of the work which took place: a battle which I regret was lost.

I am also grateful, for once, to have had some support from my noble friend Lord Aberdare on this matter, since he does not always agree with me. Above all, I am grateful to the noble Lord, Lord Wells-Pestell, for what he said. There were passages towards the end of his carefully prepared speech which will make interesting reading. He is beginning to feel what I believe many people are feeling to-day, that what is needed on these matters is a proper code of ethics. The noble Lord also made perhaps the rather startling suggestion that there was the underlying implication in some speeches that some of us thought there were lower standards among the local authorities' social workers. I do not think that anybody has ever suggested that, nor that any Member of your Lordships' House even intended to suggest such a thing. What needs to be emphasised is that the hospital social worker teams have been small, compact and forming part of a clinical team. Some of the anxiety here comes from some social workers who will be "outposts" from a larger Department They may feel that the knowledge they derive from their clinical work under the National Health Service will be known by some people who should not know it. It is as simple as that; but I think that some of the things said by the noble Lord will be very helpful in allaying any such fears in that direction.


My Lords, would the noble Lord just allow me to express my personal thanks to him for having removed any doubt that lower standards might have been imputed. I am sure local authority social workers, if and when they read the report of this debate, will be glad to be reassured that no one suggests there are two different standards.


My Lords, I am glad that the noble Lord derives comfort from that because, as I said, not only to-day do I think that no Member has made any such suggestion, but on the previous occasion when I raised this matter did anybody make such a suggestion: rather the reverse. Putting it in material terms, the local authority social workers are, on the whole, far better paid than medical social workers. This is one of the reasons why the hospital social worker has been in some trouble in this respect. In so far as that is a gauge of merit, I suppose one might say they are of higher standard.

I must make one complaint, which is that the noble Lord once again laid down a ruling and, again, seemed to be confusing the two kinds of records I spoke of earlier. He confirmed that the medical records are the property of the Secretary of State—which is what we all know—and in effect really confirmed to-day that the social workers' files are the property of the local authority, which is what I said. There will still be difficulty in this sphere, and I notice he made no attempt to answer my extract from the letter about the local government Ombudsman. Perhaps he will consider this and let me know his answer as regards the dangers implicit in that matter at some future time. Once again, I should like to express my gratitude to your Lordships for the patience with which you have listened to me.


My Lords, before the noble Lord sits down, may I say that I did intend to reply to him regarding the Ombudsman point. I wonder whether he would care to put a Question to me about that and I shall then be able to notify the whole House of the answer.


My Lords, I am much obliged. I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.