Provision of medical reports

The provision of medical reports is governed by the Access to Medical Reports Act 1988 (AMRA). This gives patients in the UK the right of access to medical reports written about them for employment, insurance or similar purposes (such as requests from a government department or agency assessing a claimant’s entitlement to benefits). Specific provisions exist for Northern Ireland under the Access to Personal Files and Medical Reports Order 1991.

This legislation extends only to reports on the physical or mental health of the patient, prepared by a medical practitioner who is or has been responsible for the care of the individual. The provisions do not therefore cover occupational physicians who are assessing patients for employment purposes and who have no direct responsibility for the clinical care of the patient.

Basic considerations

An organisation seeking a medical report must obtain the patient’s consent to do so, and also inform the patient of their rights under the AMRA 1988, as set out below.

The patient is entitled to access the report before it is submitted. The patient should arrange this with their doctor within 21 days of the report being requested by the organisation. Alternatively, if a patient initially consents to the report being submitted but then changes their mind and wants to view the report before it is submitted, they will have 21 days from the date they notified the doctor to view it. Otherwise, if the patient does not contact the GP, the report can be submitted without their consent once 21 days have elapsed from the date of the application. The medical practitioner may charge a reasonable fee for providing a copy to the patient.

A patient may request (in writing) amendments to the report if they believe that any part of it is incorrect or misleading. The doctor can either agree to the amendments or decline to amend but offer the option of sending the report with a statement of the patient’s views attached. The patient retains the right to remove their consent to the report being sent.

GMC guidance for doctors states that “you must be honest and trustworthy when writing reports and you must not leave out relevant information”. It is for the doctor to decide whether or not any contested information is relevant. If requested amendments are agreed, the applicant is not entitled to know that the original report has been changed.

A copy of the report should be retained for at least six months from the date it was supplied and, during this period, the patient is entitled to access the report. The doctor may refuse access to part or all of the report if its disclosure would be likely to cause serious harm to the patient or others. The patient should be informed of any applicable restrictions and the remainder of the document if applicable, should be made available. Third party information should also be withheld.

Common pitfalls

• Providing a medical report to the applicant without ensuring that valid consent has been provided by the patient. It is best practice for the consent to be mandated in a written and dated format.
• Sending a medical report to the applicant within 21 days from the application date without allowing the patient to view if requested.
• Not considering whether the patient has fully understood their rights. In such circumstances it may be prudent to try to make contact with the patient before sending the report.
• Applying excessive or inconsistent charges for providing copies of medical reports to patients.
• Failing to note a patient’s objections to information contained in the report and sending it on to the applicant without valid consent.

Key points

• Carefully check if specific clinical considerations are required in a report
• Ensure that patients’ legal rights under the AMRA 1988 have been fully considered, documented as appropriate and addressed before any final report is sent to an applicant agency.

Further guidance

• Access to Medical Reports Act 1988
• Faculty of Occupational Health. Good Occupational Medical Practice
• GMC. Confidentiality: good practice in handling patient information (Disclosure for the protection of patients and others)
• GMC. Confidentiality: good practice in handling patient information (Disclosing information for employment, insurance and similar purposes)
• GDC. Focus on standards (Principle 4: Maintain and protect patients’ information)

MDDUS Training & CPD resources