All GP practices in England must now provide patients with online services to book appointments, order repeat prescriptions and review summary information held in their patient records.
One area where practices are now facing challenges is around proxy access rights and limitations. Practices must consider the following when it comes to providing access to medical records to those other than the patient themselves.
As per the Mental Capacity Act 2005, patients over the age of 16 are presumed to have capacity and can therefore be given appropriate passwords to gain access to online services.
A competent individual can also request to nominate another person to deal with their medical matters. Any request for proxy access would require the express consent of the patient, with an understanding that the consent can be revoked at any time on the patient’s notice to the practice.
11 years and under
Some practices incorrectly assume that the parent or guardian of a child under the age of 16 has an automatic right to proxy access. It is important that practices do not have this as a default position.
Guidance published by the RCGP and NHS England makes it clear that parents and guardians only have access rights up until the age of 11. However, there may be exceptions to this on a case by case basis.
Proxy access should be automatically deactivated when a patient turns 11, and the child should be invited to discuss delegate access in the lead up to their birthday. In order to ensure that the child does not feel coerced into a decision, these discussions are sometimes, but not always, best had without the parent being present.
An assessment of the child’s capacity is required and should they lack capacity, the proxy access can then be reinstated.
On the other hand, children who are able to make independent and informed decisions should be actively involved in decisions regarding who can access their information.
Final decisions should always consider the child’s best interests as paramount. It is common for patients between the ages of 11-16 to have only appointment making facilities and repeat prescriptions available to the proxy, for practical reasons, and have other details such as clinical records hidden.
However, this can prove to be a problem for some medications, such as the contraceptive pill, and GPs therefore need to preempt this by ensuring certain prescription information cannot be seen by parents, at the child’s request.
Proxy access should automatically switch off for parents when their child turns 16. Where a child between the ages of 16 and 18 years appears to not have the capacity to manage their healthcare needs or is doing so in a way that is detrimental to their health, GPs may decide that proxy access should be given to, or remain with, the parents.
It is not uncommon for practices to become caught between warring parents following a separation. Where access is requested by an estranged parent, the same process as above should be considered and the first step should be to determine whether the child has capacity to consent to the access. If not, then the practice must clarify whether the parent requesting access has parental responsibility and evidence of this should be sought.
It is always best to encourage collaborative approaches with both parents where possible. In the spirit of openness, if one parent already has proxy access, they should be notified of the other’s request, but they do not have the right to oppose it. They can, however, provide evidence to demonstrate that the parent requesting access has had their parental responsibility revoked or that allowing access would be detrimental to the interests of the child.
It would ultimately be for the GP to decide whether to grant full proxy access or limit information. In some circumstances it may be appropriate for a parent who does not retain parental responsibility but looks after the child periodically to have access to online booking or current medication lists in the interests of the ongoing health of the child.
Adult patients who lack capacity
Where a patient has a lasting power of attorney (LPA) in place under the Mental Capacity Act 2005, or a deputyship has been ordered by the court of protection, then proxy access can be provided to the nominated person.
Where such provisions do not exist, next of kin or carers may request proxy access. It is the GP’s responsibility to ensure that access is only granted where necessary and in the patient’s best interests. In the case of an LPA or carer, access should be limited to the minimum required to care for the patient.
The provision of proxy access is ultimately at the discretion of the GP and decisions should be clearly documented in the patient’s medical records so that the rationale is apparent.
Automatic proxy access revocation first occurs at age 11, generally for past appointments and clinical records, and at 16 for all services. However, this is subject to the patient’s capacity.
Access should also be revoked if the proxy acts in a way which is detrimental to the health or wellbeing of the patient, regardless of whether they are a child or adult who lacks capacity.
- Dr Bradshaw is senior medicolegal adviser at the Medical Protection Society (MPS)