== Organised policy ==

The organised policy for consent and confidentiality should be part of the hospital’s or trusts overall strategy for patient care whether as a part of internal management structures or part of the Patient’s Charter programme. As Hart A.1984 comments with regard to the audiovisual recordings of patients;

''“However, as often happens with rapid technological innovation, it is doubtful whether the institutional and organisational frameworks have successfully adapted to the pace of change.”''

In the past organised policies have been developed at different levels from the work of professional bodies like the Institute of Medical Illustrators (IMBI 1985), at regional level North East Thames Regional Health Authority (Gilson CC et al 1984, Cull PG et al 1986, Cull P, 1986, NETRHA 1987) and individual departments throughout the country.

The drive since 1st April 1992 to develop Local Charter Standards within individual Trusts and hospitals should lead to a greater concern for the welfare of the patient in the medical process, including the issues of consent and confidentiality (NHS 1992).

'''The Patient’s Charter Rights'''

1. to receive health care of the basis of clinical need, regardless of ability to pay;

2. to be registered with a GP;

3. to receive emergency medical care at any time, through your GP or the emergency ambulance service and hospital accident and emergency departments;

4. to be referred to a consultant, acceptable to you, when your GP thinks it necessary, and to be referred for a second opinion if you and your GP agree this is desirable;

5. to be given a clear explanation of any treatment proposed, including any risks and any alternatives, before you decide whether you will agree to the treatment;

6. to have access to your health records, and to know that those working for the NHS are under a legal duty to keep their contents confidential;

7. to choose whether or not you wish to take part in medical research or medical student training.

and since 1st April 1992;

1. to be given detailed information on local health services, including quality standards and maximum waiting times.

2. to be guaranteed admission for treatment by a specific date no later than two years from the day, when your consultant places you on a waiting list.

3. to have any complaint about NHS services - whoever provides them - investigated and to receive a full and prompt reply from the chief executive or general manager.

Reports like that for the Cleveland crisis (Butler-Sloss 1988) and [http://www.bristol-inquiry.org.uk/ The Bristol Royal Infirmary Inquiry] have added weight to the necessity for comprehensive reviews of consent policies.

It is important that as producers of particularly confidential material medical illustrators should be closely involved in the development of hospital guidelines and policy in this area. Even if we are not involved in the development of such policy matters we still need to be advised of any changes and most importantly make sure that details are available in the department of the following;

- List of persons able to give permission for release of photographs eg. as evidence to police, eg. consultant, unit general manager etc.

- Know of the hospitals procedures for patients suspected of being abused.

- List of persons who can give advice about ethically complicated situations that arise.

- Copies of the hospitals local charter standards

- Copies of policy documents relating to consent and confidentiality

- Ensure that the Medical Illustration Department is on the hospital’s mailing list for such material.

I am sure you can add other important information to this list relevant to your own situation.

== Development of guidelines or code of practice ==

Guidelines for consent to the photographic process and confidentiality of such clinical materials are best developed in the medical illustration department. Now that we are in a situation that policies have been published and promoted nationally, see section on Consent, our job isn't over it has just started. Just because there is a policy in place doesn't mean people know about it, have read it or are following it. We do have to avoid being the "policemen" we cannot assume that we are the only ones concerned about consnet and confidentiality. A major area of change has been the Vancouver agreements regarding consent for publication whcih especially addresses the use of photographs and having proper consent, author's instructions for medical journals make this very clear. See [http://www.icmje.org/ International Committee of Medical Jourenal Editors - Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication] [http://bmj.bmjjournals.com/advice/editorial_policies.shtml#patient British Medical Journal - Editorial policies]

'''Policy review or critical reflection'''

The first element should be a comprehensive review of what you are actually doing, in this way you can look at what is good and not so good in your own practice.

How would you go about assessing how you and your department control the consent process and confidentiality?

The following methods could be useful in assessing your own or your departments practice:

- Questionnaire for staff and patients to analyse what you are doing.

- Send through a mock patient at different times with different photographers and see how they react to your consent procedure.

- Imagine you are the patient and how you would feel about going through the photographic and consent process.

- For confidentiality imagine it is a picture of you going through the department.

- External assessor, ask someone from another hospital, department or management to look at how you undertake the consent process.

This can be in as much detail as down to the way patients enter the department and are greeted, the waiting area, state of the studio, changing areas, manner of addressing the patients, chaperones, where the films go, who can see transparencies and prints while they are in the department and so on. The design of the consent form is only a small element in the overall process and should be part of the procedure or guidelines established.

When something goes wrong the way it was undertaken can be examined in relation to the code of practice and appropriate action taken through disciplinary procedures or tightening up of the code to prevent a recurrence, this is termed critical incident analysis.

As Gilson CC et al 1984 commented;

''“We cannot prescribe against all eventualities; determination to pursue a certain course will succeed in spite of all obstacles. However the Authority and its employees will have done their duty if all reasonable steps have been taken.”''

== Legal proscription v’s self-regulation ==

The law lays down a framework by which the methods of photographers or clinicians are tested. Exact procedures necessary like consent arise out of the case law that is developed as cases go through the courts. Patients have legal redress for compensation.
Self-regulation relies on general methods in use the “best practice’’ (Independent Second Opinion Panel 1988).
Breaches of ethics are often publicised (Anon 1984, Cull P 1986) and codes of conduct develop out of these. Accreditation schemes (Cull P 1986) such as the National Board of Registration of Medical Illustrators rely on the adherence of practitioners to codes of conduct and to national laws that are in force.
Legal codification    Self-regulation
Legal restrictions specified     Personal and professional
and tested by legal cases.    responsibility
    Adherence to codes of practice/
    conduct
    Compulsory                    Voluntary
If we do not make sure that our own house is kept in order it is likely that laws will be introduced to curtail photographic abuse of privacy. Even if the current addition to the Copyright, Designs and Patents Act does not go through, further flagrant abuse by newspaper photographers may lead to Government legislation that will go onto the statute books, that will affect our consent procedures.

== Resources ==

'''Weblinks'''

[http://www.bristol-inquiry.org.uk/ The Bristol Royal Infirmary Inquiry]

[http://bmj.bmjjournals.com/advice/editorial_policies.shtml#patient British Medical Journal - Editorial policies]

[http://www.wma.net/e/policy/b3.htm World  Medical Association Declaration of Helsinki]

'''References'''

Butler-Sloss E. (1988) Report of the inquiry into child abuse in Cleveland 1987. Cm 412. London: HMSO.

Cull PG Gilson CC. (1986) Confidentiality of illustrative clinical records - a code of practice, guidance notes and recommendations. J Audiovis Media Med; 9: 124-30.

Cull P. (1988) Aspects of confidentiality, copyright, and accreditation. J Audiovis Media Med 1988; 11: 8-10.

Cull PG Gilson CC. (1986) Confidentiality of illustrative clinical records - a code of practice, guidance notes and recommendations. J Audiovis Media Med; 9: 124-30.

Hart A. (1984) In confidence: Some implications of audiovisual recordings of patients. J Audiovis Media Med; 7: 4-50.

IMBI Council. (1985) The responsibility of professional medical illustrators in preserving patient confidentiality. IMBI Information sheet 8; January: 3.

NHS. (1992) The Patient’s Charter. London: HMSO.

North East Thames Regional Health Authority. (1987) Accreditation of personnel involved in the production of illustrative clinical records. NETHRA (Audiovisual Advisory Committee); Personal communication.