Our staff are committed to providing quality healthcare for the benefit of all of our patients. View our policies to see how this is achieved:
Privacy Policy
PRIVACY NOTICE
Your information, what you need to know
This privacy notice explains why we collect information about you, how that information may be used, how we keep it safe and confidential and what your rights are in relation to this.
Why we collect information about you
Health care professionals who provide you with care are required by law to maintain records about your health and any treatment or care you have received within any NHS organisation. These records help to provide you with the best possible healthcare and help us to protect your safety. We collect and hold data for providing healthcare services to our patients and running our organisation which includes monitoring the quality of care that we provide. In carrying out this role we may collect information about you which helps us respond to your queries or secure specialist services. We may keep your information in written form and/or in digital form. The records may include basic details about you, such as your name and address. They may also contain more sensitive information about your health and also information such as outcomes of needs assessments.
Details we collect about you
The health care professionals who provide you with care maintain records about your health and any treatment or care you have received previously (e.g. from Hospitals, GP Surgeries, A&E, etc.). These records help to provide you with the best possible healthcare. Records which this GP Practice may hold about you include the following:
- Details about you, such as your address and next of kin
- Any contact the surgery has had with you, such as appointments, clinicvisits, emergency appointments,
- Notes and reports about your health
- Details about your treatment and care
- Results of investigations, such as laboratory tests, x-rays,
- Relevant information from other health professionals, relatives or your carers
How we keep your information confidential and safe
Everyone working for our organisation is subject to the Common Law Duty of Confidence. Information provided in confidence will only be used for the purposes advised with consent given by the patient, unless there are other circumstances covered by the law.
The NHS Digital Code of Practice on Confidential Information applies to all NHS staff and they are required to protect your information, inform you of how your information will be used, and allow you to decide if and how your information can be shared. All our staff are expected to make sure information is kept confidential and receive regular training on how to do this.
The health records we use may be electronic, on paper or a mixture of both, and we use a combination of working practices and technology to ensure that your information is kept confidential and secure. Your records are backed up securely in line with NHS standard procedures.
We ensure that the information we hold is kept in secure locations, is protected by appropriate security and access is restricted to authorised personnel. We also make sure external data processors that support us are legally and contractually bound to operate and prove security arrangements are in place where data that could or does identify a person are processed. We are committed to protecting your privacy and will only use information collected lawfully in accordance with:
- Data Protection Act 2018
- General Data Protection Regulation
- Human Rights Act
- Common Law Duty of Confidentiality
- NHS Codes of Confidentiality and Information Security
- Health and Social Care Act 2015
- And all applicable legislation
We maintain our duty of confidentiality to you at all times. We will only ever use or pass on information about you if we reasonably believe that others involved in your care have a genuine need for it. We will not disclose your information to any third party without your permission unless there are exceptional circumstances (such as a risk of serious harm to yourself or others) or where the law requires information to be passed on.
How we use your information
Improvements in information technology are also making it possible for us to share data with other healthcare organisations for providing you, your family and your community with better care. For example, it is possible for healthcare professionals in other services to access your record with your permission when the practice is closed. This is explained further in the Local Information Sharing section below.
Under the powers of the Health and Social Care Act 2015, NHS Digital can request personal confidential data from GP Practices without seeking patient consent for a number of specific purposes, which are set out in law. These purposes are explained below.
You may choose to opt-out to personal data being shared for these purposes. When we are about to participate in a new data-sharing project we aim to display prominent notices in the Practice and on our website four weeks before the scheme is due to start.
Instructions will be provided to explain what you have to do to ‘opt-out’ of the new scheme. Please be aware that it may not be possible to opt out of one scheme and not others, so you may have to opt out of all the schemes if you do not wish your data to be shared.
You can object to your personal information being shared with other healthcare providers which will not affect your entitlement to care, but you should be aware that this may, in some instances, affect your care as important information about your health might not be available to healthcare staff in other organisations. If this limits the treatment that you can receive then the practice staff will explain this to you at the time you object.
To ensure you receive the best possible care, your records are used to facilitate the care you receive. Information held about you may be used to help protect the health of the public and to help us manage the NHS.
Child Health Information
We wish to make sure that your child has the opportunity to have immunisations and health checks when they are due. We share information about childhood immunisations, the 6-8 week new baby check and breast-feeding status with NHS CLCH health visitors and school nurses, and with NEL Commissioning Support Unit, who provide the Child Health Information Service on behalf of NHS England.
Clinical audit
Information may be used by the Clinical Commissioning Group for clinical audit to monitor the quality of the service provided to patients with long terms conditions. Some of this information may be held centrally and used for statistical purposes (e.g. the National Diabetes Audit). When this happens, strict measures are taken to ensure that individual patients cannot be identified from the data.
Clinical Research
Sometimes anonymised data may be used for research purposes – but we will normally ask your permission before releasing any information for this purpose which could be used to identify you.
In some instances, the Confidentially Advisory Group, part of the Health Research Authority may allow for identifiable information to be shared with researchers without consent of individuals. You may however opt-out of this, details of which can be found below under the ‘National Data Opt-Out’.
Improving Diabetes Care and long-term condition management
Information that does not identify individual patients is used to enable focussed discussions to take place at practice-led local diabetes and long term condition management review meetings between health care professionals. This enables the professionals to improve the management and support of these patients.
Individual Funding Request
An ‘Individual Funding Request’ is a request made on your behalf, with your consent, by a clinician, for funding of specialised healthcare which falls outside the range of services and treatments that CCG has agreed to commission for the local population. An Individual Funding Request is taken under
consideration when a case can be set out by a patient’s clinician that there are exceptional clinical circumstances which make the patient’s case different from other patients with the same condition who are at the same stage of their disease, or when the request is for a treatment that is regarded as new or experimental and where there are no other similar patients who would benefit from this treatment. A detailed response, including the criteria considered in arriving at the decision, will be provided to the patient’s clinician.
Invoice Validation
Invoice validation is an important process. It involves using your NHS number to check which Clinical Commissioning Group is responsible for paying for your treatment. Section 251 of the NHS Act 2006 provides a statutory legal basis to process data for invoice validation purposes. We can also use your NHS number to check whether your care has been funded through specialist commissioning, which NHS England will pay for. The process makes sure that the organisations providing your care are paid correctly.
Local Information Sharing
Your GP electronic patient record is held securely and confidentially on an electronic system managed by your registered GP practice. If you require attention from a local health or care professional outside of your usual practice services, such as in an Evening and Weekend GP HUB services, Emergency Department, Minor Injury Unit or Out Of Hours service, the professionals treating you are better able to give you safe and effective care if some of the information from your GP record is available to them. If those services use a TPP clinical system your full SystmOne medical record will only be shared with your express consent.
Where available, this information can be shared electronically with other local healthcare providers via a secure system designed for this purpose. Depending on the service you are using and your health needs, this may involve the healthcare professional accessing a secure system that enables them to view either parts of your GP electronic patient record (e.g. your Summary Care Record) or a secure system that enables them to view your full GP electronic patient record (e.g. TPP SystmOne medical records or EMIS remote consulting system).
In all cases, your information is only accessed and used by authorised staff who are involved in providing or supporting your direct care. Your permission will be asked before the information is accessed, other than in exceptional circumstances (e.g. emergencies) if the healthcare professional is unable to ask you and this is deemed to be in your best interests (which will then be logged).
If your Practice uses the TPP SystmOne software, you are able to choose whether other health and care providers can access your information to help provide you with care. More information about this, and how to do so, can be found here.
National Fraud Initiative – Cabinet Office
The use of data by the Cabinet Office for data matching is carried out with statutory authority under Part 6 of the Local Audit and Accountability Act 2014. It does not require the consent of the individuals concerned under the Data Protection Act 2018. Data matching by the Cabinet Office is subject to a Code of Practice. For further information see:
https://www.gov.uk/government/publications/code-of-data-matching-practice-for-national-fraud-initiative
National Registries
National Registries (such as the Learning Disabilities Register) have statutory permission under Section 251 of the NHS Act 2006, to collect and hold service user identifiable information without the need to seek informed consent from each individual service user.
Risk Stratification
‘Risk stratification for case finding’ is a process for identifying and managing patients who have or may be at-risk of health conditions (such as diabetes) or who are most likely to need healthcare services (such as people with frailty). Risk stratification tools used in the NHS help determine a person’s risk of suffering a particular condition and enable us to focus on preventing ill health before it develops.
Information about you is collected from a number of sources including NHS Trusts, GP Federations and your GP Practice. A risk score is then arrived at through an analysis of your de-identified information. This can help us identify and offer you additional services to improve your health.
Risk-stratification data may also be used to improve local services and commission new services, where there is an identified need. In this area, risk stratification may be commissioned by the NWL Clinical Commissioning Groups. Section 251 of the NHS Act 2006 provides a statutory legal basis to process data for risk stratification purposes. Further information about risk stratification is available from: https://www.england.nhs.uk/ourwork/tsd/ig/risk-stratification /
If you do not wish information about you to be included in any risk stratification programmes, please let us know. We can add a code to your records that will stop your information from being used for this purpose. Please be aware that this may limit the ability of healthcare professionals to identify if you have or are at risk of developing certain serious health conditions.
Safeguarding
To ensure that adult and children’s safeguarding matters are managed appropriately, access to identifiable information will be shared in some limited circumstances where it’s legally required for the safety of the individuals concerned.
Summary Care Record (SCR)
The NHS in England uses a national electronic record called the Summary Care Record (SCR) to support patient care. It contains key information from your GP record. Your SCR provides authorised healthcare staff with faster, secure access to essential information about you in an emergency or when you need unplanned care, where such information would otherwise be unavailable.
Summary Care Records are there to improve the safety and quality of your care. SCR core information comprises your allergies, adverse reactions and medications. An SCR with additional information can also include reason for medication, vaccinations, significant diagnoses / problems, significant procedures, anticipatory care information and end of life care information. Additional information can only be added to your SCR with your agreement.
Please be aware that if you choose to opt-out of SCR, NHS healthcare staff caring for you outside of this surgery may not be aware of your current medications, allergies you suffer from and any bad reactions to medicines you have had, in order to treat you safely in an emergency. Your records will stay as they are now with information being shared by letter, email, fax or phone. If you wish to opt- out of having an SCR please return a completed opt-out form to the practice.
Supporting Medicines Management
NWL Clinical Commissioning Groups use pharmacist and prescribing advice services to support local GP practices with prescribing queries, which may require identifiable information to be shared. These pharmacists work with your usual GP to provide advice on medicines and prescribing queries, and review prescribing of medicines to ensure that it is appropriate for your needs, safe and cost-effective. Where specialist prescribing support is required, the CCG medicines management team may provide relating to obtaining medications on behalf of your GP Practice to support your care.
Supporting Locally Commissioned Services
CCGs support GP practices by auditing anonymised data to monitor locally commissioned services, measure prevalence and support data quality. The data does not include identifiable information and is used to support patient care and ensure providers are correctly paid for the services they provide.
Suspected Cancer
Data may be analysed in cases of suspected cancer by The Royal Marsden NHS Trust, The Royal Brompton Hospital, Imperial College Healthcare NHS Trust , Chelsea and Westminster Hospital NHS Foundation Trust, London North West Healthcare NHS Trust and University College London Hospitals NHS Foundation Trust to facilitate the prevention, early diagnosis and management of illness. Measures are taken to ensure the data for analysis does not identify individual patients.
Data Retention
We manage patient records in line with the Records Management NHS Code of Practice for Health and Social Care which sets the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England, based on current legal requirements and professional best practice.
Who are our partner organisations?
We may also have to share your information, subject to strict agreements on how it will be used, with the following types of organisations:
- NHS Trusts
- Specialist Trusts
- GP Federations
- Independent Contractors such as dentists, opticians, pharmacists
- Private Sector Providers
- Voluntary Sector Providers
- Ambulance Trusts
- Clinical Commissioning Groups
- Social Care Services
- Local Authorities
- Education Services
- Fire and Rescue Services
- Police
- Other ‘data processors’
Specific details of the organisations with whom we share your data can be seen here:
Central London – http://www.centrallondonccg.nhs.uk/what-we-do/your-patient-record.aspx
We will never share your information outside of health partner organisations without your consent unless there are exceptional circumstances such as when the health or safety of others is at risk, where the law requires it or to carry out a statutory function. No information will ever be shared where we do not have a lawful basis to do so.
Within the health partner organisations (NHS and Specialist Trusts) and in relation to the above mentioned themes – Risk Stratification, Invoice Validation, Supporting Medicines Management, Summary Care Record –your information to be shared unless you choose to opt-out (see below).
This means you will need to express an explicit wish to not have your information shared with the other organisations; otherwise it will be automatically shared. We are required by law to report certain information to the appropriate authorities. This is only provided after formal permission has been given by a qualified health professional. There are occasions when we must pass on information, such as notification of new births, where we encounter infectious diseases which may endanger the safety of others, such as meningitis or measles (but not HIV/AIDS), and where a formal court order has been issued. Our guiding principle is that we are holding your records in strictest confidence.
Right to withdraw consent to share personal information (Opt- Out)
If you are happy for your data to be extracted and used for the purposes described in this privacy notice then you do not need to do anything. If you do not want your information to be used for any purpose beyond providing your care you can choose to opt-out. If you wish to do so, please let us know so we can code your record appropriately. We will respect your decision if you do not wish your information to be used for any purpose other than your care but in some circumstances we may still be legally required to disclose your data. There are two main types of opt-out:
Type 1 Opt-Out
If you do not want information that identifies you to be shared outside the practice, for purposes beyond your direct care, you can register a ‘Type 1 Opt-Out’. This prevents your personal confidential information from being used other than in particular circumstances required by law, such as a public health emergency like an outbreak of a pandemic disease. Please talk to a member of staff at your Practice to initiate the type 1 opt-out.
National Data Opt-Out
NHS Digital have created a new opt-out system named the National Data Opt-Out which allows individuals to opt-out of their information being used for planning and research purposes. From 25 May 2018, NHS Digital has had to apply this opt-out for all their data flows, and from 2020 all health and care organisations will have to ensure the opt-out is respected. Individuals who previously opted out with a ‘Type 2’ objection will not have to do anything as you will be automatically be opted out.
If you wish to apply the National Opt-Out, please go to NHS Digitals website here https://www.nhs.uk/your-nhs-data-matters/
Access to your information
Under the Data Protection Act 2018 everybody has the right to see, or have a copy, of data we hold that can identify you, with some exceptions. You do not need to give a reason to see your data. If you want to access your data you must make the request in writing or speak to a member of the Practice staff. Under special circumstances, some information may be withheld. If you wish to have a copy of the information we hold about you, please contact a member of staff at Woodfield Road Surgery.
Change of Details
It is important that you tell the person treating you if any of your details such as your name or address have changed or if any of your details are incorrect in order for this to be amended. Please inform us of any changes so our records for you are accurate and up to date.
Mobile telephone number
If you provide us with your mobile phone number we may use this to send you reminders about your appointments or other health screening information. Please let us know if you do not wish to receive reminders on your mobile.
Notification
The Digital Economy 2017 requires organisations to register a notification with the Information Commissioner to describe the purposes for which they process personal data. We are registered as a data controller and our registration can be viewed online in the public register at:http://ico.org.uk/what_we_cover/register_of_data_controllers
Any changes to this notice will be published on our website and in a prominent area at the Practice.
Complaints
If you have concerns or are unhappy about any of our services, please contact one of the Practice Managers, Leiola Jefferson or Leigh Kerridge at Woodfield Road Surgery, The Medical Centre, 7e Woodfield Road, London W9 3XZ or telephone 020 7266 1449.
Phone: 0303 123 1113
Website: www.ico.orguk |
For independent advice about data protection, privacy and data-sharing issues, you can contact:
The Information Commissioner
Wycliffe House
Water Lane
Wilmslow Cheshire SK9 5AF
Information we are required to provide you
Data Controller
contact details |
Dr Susan Honey, Woodfield Road Surgery, The Medical Centre, 7e Woodfield Road, London W9 3XZ |
Data Protection Officer contact details | Dr. Ernest Norman-Williams <nwl.infogovernance@nhs.net> |
Purpose of the processing for the provision of your healthcare
|
· To give direct health or social care to individual patients.
· For example, when a patient agrees to a referral for direct care, such as to a hospital, relevant information about the patient will be shared with the other healthcare staff to enable them to give appropriate advice, investigations, treatments and/or care.
· To check and review the quality of care. (This is called audit and clinical governance). |
Lawful basis for processing
for the provision of your healthcare
|
These purposes are supported under the following sections of the GDPR:
Article 6(1)(e) ‘…necessary for the performance of a task carried out in the public interest or in the exercise of official authority…’; and
Article 9(2)(h) ‘necessary for the purposes of preventative or occupational medicine for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services…”
Healthcare staff will also respect and comply with their obligations under the common law duty of confidence. |
Purpose of the processing for medical research and to measure quality of care | Medical research and to check the quality of care which is given to patients (this is called national clinical audit). |
Lawful basis for processing for medical research and to measure the quality of care
|
The following sections of the GDPR mean that we can use medical records for research and to check the quality of care (national clinical audits)
Article 6(1)(e) – ‘processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller’.
For medical research: there are two possible conditions.
Either: Article 9(2)(a) – ‘the data subject has given explicit consent…’ Or: Article 9(2)(j) – ‘processing is necessary for… scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member States law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and interests of the data subject’.
To check the quality of care (clinical audit): Article 9(2)(h) – ‘processing is necessary for the purpose of preventative…medicine…the provision of health or social care or treatment or the management of health or social care systems and services…’
|
Purpose of the processing to meet legal requirements | Compliance with legal obligations or court order. |
Lawful basis for processing to meet legal requirements | These purposes are supported under the following sections of the GDPR:
Article 6(1)(c) – ‘processing is necessary for compliance with a legal obligation to which the controller is subject…’
Article 9(2)(g) – ‘processing is necessary for reasons of substantial public interest, on the basis of Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject;
Schedule 1 part 2 of the Data Protection Act 2018 lists the substantial public interest conditions, of which paragraph 2 states data can be processed when the purpose is for the exercise of function conferred on a person by enactment or rule of law. |
Purpose of the processing for National screening programmes
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· The NHS provides several national health screening programmes to detect diseases or conditions early such as cervical and breast cancer, aortic aneurysm and diabetes.
· The information is shared so that the correct people are invited for screening. This means those who are most at risk can be offered treatment. |
Lawful basis for processing
for National screening programmes
|
The following sections of the GDPR allow us to contact patients for screening.
Article 6(1)(e) – ‘processing is necessary…in the exercise of official authority vested in the controller…’’
Article 9(2)(h) – ‘processing is necessary for the purpose of preventative…medicine…the provision of health or social care or treatment or the management of health or social care systems and services…’ |
Lawful basis for processing for employment purposes | The following sections of GDPR allow us to process staff data in an employment capacity
Article 6(1)(b) – ‘processing is necessary for compliance with a legal obligation’
Article 9(2)(b) – ‘processing is necessary for the purposes of carrying out the obligations and exercising specific rights of the controller or of the data subject in the field of employment … law in so far as it is authorised by Union or Member State law or a collective agreement pursuant to Member State law providing for appropriate safeguards for the fundamental rights and the interests of the data subject;’ |
Rights to object
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· You have the right to object to information being shared between those who are providing you with direct care.
· This will not affect your entitlement to care, but this may affect the care you receive – please speak to the practice. · Any objection will be reviewed by the Practice and a decision taken on whether to uphold the request. The right to object is not an absolute right. · In appropriate circumstances it is a legal and professional requirement to share information for safeguarding reasons. This is to protect people from harm. · The information will be shared with the local safeguarding service in the London Borough of Westminster |
Right to access and correct | · You have the right to access your medical record and have any errors or mistakes corrected. Please speak to a member of staff or look at our ‘subject access request’ (Appendix A – please see link below).
· You have the right to request rectification of your record if you believe information contained within it is wrong. Information will only be deleted in very exceptional circumstances. In most instances the original information will be retained on the record noting the rectified information. |
Retention period
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GP medical records will be kept in line with the law and national guidance. Information on how long records are kept can be found at: https://digital.nhs.uk/article/1202/Records-Management-Code-of-Practice-for-Health-and-Social-Care-2016
or speak to the practice. |
Right to complain
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You have the right to complain to the Information Commissioner’s Office. You may follow this link https://ico.org.uk/global/contact-us/ or call the helpline 0303 123 1113 |
Data we get from other organisations | We receive information about your health from other organisations who are involved in providing you with health and social care. For example, if you go to hospital for treatment or an operation the hospital will send us a letter to let us know what happens. This means your GP medical record is kept up-to date when you receive care from other parts of the health service. |
The NHS Care Record Guarantee
The NHS Care Record Guarantee for England sets out the rules that govern how patient information is used in the NHS, what control the patient can have over this, the rights individuals have to request copies of their data and how data is protected under the Data Protection Act 2018.
http://systems.digital.nhs.uk/infogov/links/nhscrg.pdf
The NHS Constitution
The NHS Constitution establishes the principles and values of the NHS in England. It sets out the rights patients, the public and staff are entitled to. These rights cover how patients access health services, the quality of care you’ll receive, the treatments and programmes available to you, confidentiality, information and your right to complain if things go wrong. https://www.gov.uk/government/publications/the-nhs-constitution-for-england
NHS Digital
NHS Digital collects health information from the records health and social care providers keep about the care and treatment they give, to promote health or support improvements in the delivery of care services in England.
http://content.digital.nhs.uk/article/4963/What-we-collect
Reviews of and Changes to our Privacy Notice
We will keep our Privacy Notice under regular review. This notice was last reviewed in September 2018.
WOODFIELD ROAD SURGERY
Subject Access Request Policy – patients
Document Control
A. Confidentiality Notice
This document and the information contained therein is the property of Dr Susan Honey at Woodfield Road Surgery.
This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Dr Susan Honey at Woodfield Road Surgery
B. Document Details
Author and Role: | |
Organisation: | Dr Susan Honey, Woodfield Road Surgery |
Current Version Number: | 1 |
Current Document Approved By: | |
Date Approved: |
C. Document Revision and Approval History
Version | Date | Version Created By: | Version Approved By: | Comments |
1 | 01.07.2018 | FPM | ||
SUBJECT ACCESS REQUEST POLICY
Introduction
This policy provides the Practice with a process for the management of requests for personal information (for living individuals) under the Data Protection Act (DPA), the General Data Protection Regulations (GDPR) and (for deceased individuals) the Access to Health Records Act 1990.
It defines a process for achieving legislative requirements and ensuring effective and consistent management of such requests.
The policy ensures that all staff are aware of how a subject access request should be made and to respond quickly.
Under the Data Protection Act, subject to certain conditions, an individual is entitled to be:
- Told whether any personal data is being processed;
- Given a description of the personal data, the reasons it is being processed,
and whether it will be given to any other organisations or people; and - Given a copy of the information comprising the data; and given details of the source of the data (where this is available).
The Data Protection Act extends equally to all relevant records relating to living individuals, including records held in the private health sector and health professionals’ private practice records.
Personal data held by the Practice may be:-
- Personnel/Staff records relating to a member of staff, present, past or prospective, whether permanent, temporary or volunteer
- Health records consisting of information about the physical or mental health of an identifiable individual made by, or on behalf of, a health professional in connection with the care of that individual.
Access encompasses the following rights:-
- To obtain a copy of the record in permanent form
- To have information provided in an intelligible format (and explained where necessary)
The Data Protection Act also gives subjects who now reside outside the UK the right to apply for access to their former UK health and employment records:
- Employees are legally entitled to request their personal records and may take them outside of the UK at their own discretion.
- Original health records should not be given to people to keep/take outside the UK. A GP or community health professional may be prepared to provide the patient with a summary of treatment; alternatively the patient may make a request for access in the usual way.
Organisations must have procedures in place to ensure that individual’s rights of access are met within a timely and appropriate fashion.
Individual’s rights regarding the sharing of their personal information are supported by the Care Record Guarantees, which set out high-level commitments for protecting and safeguarding service user information, particularly in regard to individuals’ rights of access to their own information, how information will be shared (both within and outside of the organisation) and how decisions on sharing information will be made.
In the response to the Caldicott2 Report, the Department of Health confirmed that service users should have access to information about themselves even if it was obtained through new or non-traditional approaches (for example, virtual consultations) to delivering health and care services.
The BMA Confidentiality and Health Records Toolkit helps identify the key factors to take into consideration when making a decision around confidentiality and disclosure of health records.
Scope
This policy applies to any request by a patient or member of staff for access to their personal information held by the Practice.
This policy applies to all staff (employees, governing body members, contractors) of the Practice.
Who can make an Access Request?
An application for access to personal data may be made to the Practice by any of the following:-
- an individual
- a person authorised by the individual in writing to make the application on an individual’s behalf e.g. solicitor, family member, carer
- a person having parental responsibility for the individual where he/she is a child.
- a person appointed by a court to manage the affairs of an individual who is deemed incompetent
- individuals who hold a health and welfare Lasting Power of Attorney
- where the individual has died, the personal representative and any person who may have a claim arising out of the individual’s death (the executor of the deceased’s will; someone who has been appointed as an Administrator of the Estate by the Courts; someone who has the written consent of either of the above to be given access, someone who is in the process of challenging the deceased’s will)
The Police may, on occasion, request access to personal data of individuals. Whilst there is an exemption in the Data Protection Act which permits the Practice to disclose information to support the prevention and detection of crime, the Police have no automatic right to access; however they can obtain a Court Order.
Parental responsibility for a child is defined in the Children’s Act 1989 as ‘all the rights, duties, powers, responsibilities and authority, which by law a parent of a child has in relation to a child and his property’. Although not defined specifically, responsibilities would include safeguarding and promoting a child’s health, development and welfare, including if relevant their employment records. Included in the parental rights which would fulfil the parental responsibilities above are:
- having the child live with the person with responsibility, or having a say in where the child lives;
- if the child is not living with her/him, having a personal relationship and regular contact with the child;
- controlling, guiding and directing the child’s upbringing.
Foster parents are not ordinarily awarded parental responsibility for a child. It is more likely that this responsibility rests with the child’s social worker and appropriate evidence of identity should be sought in the usual way.
The law regards young people aged 16 or 17 to be adults for the purposes of consent to employment or treatment and the right to confidentiality. Therefore, if a 16 year old wishes HR or a medical practitioner to keep their information confidential then that wish must be respected.
In some certain cases, children under the age of 16 who have the capacity and understanding to take decisions about their own treatment are also entitled to decide whether personal information may be passed on and generally to have their confidence respected.
Where a child is considered capable of making decisions, e.g. about his/her employment or medical treatment, the consent of the child must be sought before a person with parental responsibility may be given access. Where, in the view of the appropriate professional, the child is not capable of understanding the nature of the application, the holder of the record is entitled to deny access if it is not felt to be in the patient’s best interests.
The identity and consent of the applicant must always be established.
The applicant does not have to give a reason for applying for access.
The Practice is a Data Controller and can only provide information held by the organisation. Data controllers in their own right must be applied to directly, the Practice will not transfer requests from one organisation to another.
Application
Individuals wishing to exercise their right of access should:
- Make a written application to the Practice holding the records, including via email
- Provide such further information as the Practice may require to sufficiently identify the individual
An individual may also raise a request using the form in (Appendix A – Please see link below), however this is not mandatory.
The Practice as “data controller” is responsible for ascertaining the purpose of the request and the manner in which the information is supplied.
Fees and Response Time
Under GDPR the Practice musts provide information free of charge. However, we can charge a “reasonable fee” when a request is manifestly unfounded or excessive, particularly if it is repetitive.
The fee must be based on the administrative cost of providing the information only.
The request should be initially passed to the Data Protection Officer who will manage Subject Access Request.
The request must be complied with without delay and at least within one calendar month of receipt of the request. This period can be extended for a further two months where requests are complex or numerous, however the Practice must inform the individual within one month of receipt of the request and explain why the extension is necessary.
The identity of an individual who provided/recorded information should not be disclosed, nor should the identity of any other person/s referred to in the record(s) of the individual requesting access, unless explicit consent has been given.
The Release Stage
The format of the released information must comply with the requester’s wishes. Where no specific format is requested, the Practice should provide the information in the same manner as the original request. For example, requests received via email can be satisfied via email.
The release of a health record is subject to consultation with either:-
- The health professional who is currently, or was most recently, responsible for the clinical care of the data subject in connection with the information which is the subject of the request
- Where there is more than one such health professional, the health professional who is the most suitable to advise on the information which is the subject of the request
Once the records have been collated, redacted where applicable and signed off by the Caldicott Lead, they should be sent to the requester. On no account must the original record be released.
In denying or restricting access, a reason for the decision does not need to be given but the applicant should be directed through the appropriate complaint channels.
Where information is not readily intelligible, an explanation (e.g. of abbreviations or terminology) must be given.
If it is agreed that the subject or their representative may directly inspect the record, a health professional or HR administrator must supervise the access. If supervised by an administrator, this person must not comment or advise on the content of the record and if the applicant raises enquiries, an appointment with a health professional must be offered
Exemptions
Access may be denied or restricted where:
- The record contains information which relates to or identifies a third party that is not a care professional and has not consented to the disclosure. If possible, the individual should be provided with access to that part of the record which does not contain the third party information
- Access to all or part of the record will prejudice the carrying out of social work by reason of the fact that serious harm to the physical or mental well-being of the individual or any other person is likely. If possible the individual should be provided with access to that part of the record that does not post the risk of serious harm
- Access to all or part of the record will seriously harm the physical or mental well-being of the individual or any other person. If possible the individual should be provided with access to that part of the record that does not pose the risk of serious harm
- If an assessment identifies that to comply with a SAR would involve disproportionate effort under section 8(2)(a) of the Data Protection Act (Appendix C – Please see link below).
There is no requirement to disclose to the applicant the fact that certain information may have been withheld.
In addition, Article 23 of the GDPR enables Members States, such as the United Kingdom to introduce further exemptions from the GDPR’s transparency obligations and individual rights. The Data Protection Officer can provide further information regarding exemptions applicable at the time of receipt of the subject access request.
Complaints and Appeals
The applicant has the right to appeal against the decision of the Practice to refuse access to their information. This appeal should be made to one of the Practice Managers, Leiola Jefferson / Leigh Kerridge at Woodfield Road Surgery, The Medical Centre, 7e Woodfield Road, London W9 3XZ.
If an applicant is unhappy with the outcome of their access request, the following complaints channels should be offered:
- meet with the applicant to resolve the complaint locally
- Advise a patient to make a complaint through the complaint’s process
- Advise a member of staff to consult with their trade union representative
If individuals remain unhappy with the Practice response, they have the right to appeal to the Information Commissioner’s Office:
https://www.ico.org.uk/Global/contact_us.
Information Commissioner’s Office
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF
Telephone: 0303 123 1113
Email: casework@ico.gsi.gov.uk
Roles and Responsibilities
The Caldicott Lead (Dr Susan Honey) has executive responsibility for Subject Access Requests.
The Data Protection Officer has operational responsibility for Subject Access Requests.
All staff must be aware of how to recognise and manage a subject access request. Training will be provided to staff likely to be in receipt of requests covering:-
- Required format of a subject access request
- Correct identification of the requesting individual
- Location of personal information
- Timescales for compliance
- Provision of information in an intelligible format
- Action to be taken if the information includes third party data or if it has been determined that access will seriously harm an individual (see exemptions)
Monitoring and Review
The Practice Managers monitor all Subject Access Requests to ensure the correct process has been followed and monitors any appeals/complaints relating to Subject Access Requests.
Equality Impact
In applying this policy, the organisation will have due regard for the need to eliminate unlawful discrimination, promote equality of opportunity, and provide for good relations between people of diverse groups, in particular on the grounds of the following characteristics protected by the Equality Act (2010); age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, and sexual orientation, in addition to offending background, trade union membership, or any other personal characteristic.
Chaperones
If you are having an intimate examination by your healthcare professional you or the healthcare professional may wish to have a chaperone present. If you feel you would like a Chaperone present at your consultation, please inform your Doctor/Nurse who will be more than happy to arrange this for you.
Confidentiality and Medical Records
The practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:
- To provide further medical treatment for you e.g. from district nurses and hospital services.
- To help you get other services e.g. from the social work department. This requires your consent.
- When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.
If you do not wish anonymous information about you to be used in such a way, please let us know.
Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.
Access to Records
In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so.
Freedom of Information
Information about the General Practioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.
Violence Policy
The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons. Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.
Complaints and Feedback
We make every effort to give the best service possible to everyone who attends our practice.
However, we are aware that things can go wrong resulting in a patient feeling that they have a genuine cause for complaint. If this is so, we would wish for the matter to be settled as quickly, and as amicably, as possible.
To pursue a complaint please contact the practice manager who will deal with your concerns appropriately. Further written information is available regarding the complaints procedure from reception.