How we use your medical records – Important information for patients

“How the NHS and care services use your information”

(Dr Poolo’s Surgery – RGMC is one of many organisations working in the health and care system to improve care for patients and the public).

(digital.nhs.uk)

Whenever you use a health or care service, such as attending Accident & Emergency or using Community Care services, important information about you is collected in a patient record for that service. Collecting this information helps to ensure you get the best possible care and treatment.

The information collected about you when you use these services can also be used and provided to other organisations for purposes beyond your individual care, for instance to help with:

a) improving the quality and standards of care provided

b) research into the development of new treatments

c) preventing illness and diseases

d) monitoring safety

e) planning services

This may only take place when there is a clear legal basis to use this information. All these uses help to provide better health and care for you, your family and future generations. Confidential patient information about your health and care is only used like this where allowed by law.

Most of the time, anonymous data is used for research and planning so that you cannot be identified in which case your confidential patient information isn’t needed.

You have a choice about whether you want your confidential patient information to be used in this way. If you are happy with this use of information you do not need to do anything. If you do choose to opt out your confidential patient information will still be used to support your individual care. To find out more or to register your choice to opt out, please visit www.nhs.uk/your-nhs-data-matters

On this web page you will:

a) See what is meant by confidential patient information

b) Find examples of when confidential patient information is used for individual care and examples of when it is used for purposes beyond individual care

c) Find out more about the benefits of sharing data

d) Understand more about who uses the data

e) Find out how your data is protected

f) Be able to access the system to view, set or change your opt-out setting

Find the contact telephone number if you want to know any more or to set/change your opt-out by phone

h) See the situations where the opt-out will not apply

You can also find out more about how patient information is used at: · www.hra.nhs.uk/information-about-patients/ (which covers health and care research); and · understandingpatientdata.org.uk/what-you-need-know
(which covers how and why patient information is used, the safeguards and how decisions are made)

You can change your mind about your choice at any time.

Data being used or shared for purposes beyond individual care does not include your data being shared with insurance companies or used for marketing purposes and data would only be used in this way with your specific agreement.

Health and care organisations have until 2020 to put systems and processes in place so they can be compliant with the national data opt-out and apply your choice to any confidential patient information they use or share for purposes beyond your individual care. Our organisation is currently compliant with the national data opt-out policy. “

How Dr Poolo’s Surgery – RGMC uses your information to provide you with healthcare This practice keeps medical records confidential and complies with the General Data Protection Regulation. We hold your medical record so that we can provide you with safe care and treatment. We will also use your information so that this practice can check and review the quality of the care we provide. This helps us to improve our services to you.

· We will share relevant information from your medical record with other health or social care staff or organisations when they provide you with care. For example, your GP will share information when they refer you to a specialist in a hospital. Or your GP will send details about your prescription to your chosen pharmacy. · For more information on how we share your information with organisations who are directly involved in your care can be found with in practice.

· Healthcare staff working in A&E and out of hours care will also have access to your information. For example, it is important that staff who are treating you in an emergency know if you have any allergic reactions. This will involve the use of your Summary Care Record .For more information see: digital.nhs.uk/summary-care-records or alternatively speak to your practice.

· You have the right to object to information being shared for your own care. Please speak to the practice if you wish to object. You also have the right to have any mistakes or errors corrected.

Other important information about how your information is used to provide you with healthcare

Registering for NHS care

All patients who receive NHS care are registered on a national database. · This database holds your name, address, date of birth and NHS Number but it does not hold information about the care you receive.

· The database is held by NHS Digital a national organisation which has legal responsibilities to collect NHS data.

· More information can be found at: digital.nhs.uk/home or the phone number for general enquires at NHS Digital is 0300 303 5678

Identifying patients who might be at risk of certain diseases

Your medical records will be searched by a computer programme so that we can identify patients who might be at high risk from certain diseases such as heart disease or unplanned admissions to hospital.

· This means we can offer patients additional care or support as early as possible.

· This process will involve linking information from your GP record with information from other health or social care services you have used.

· Information which identifies you will only be seen by this practice. · More information at the practice.

Safeguarding

Sometimes we need to share information so that other people, including healthcare staff, children or others with safeguarding needs, are protected from risk of harm. · These circumstances are rare.

· We do not need your consent or agreement to do this. We are required by law to provide you with the following information about how we handle your information.

Data Controller contact details Dr Poolo’s Surgery – RGMC, 261 Dagenham Rd, Dagenham, Romford RM7 0XR 01708 209220

Data Protection Officer contact details Chris Kitchener DPO / NEL NHS Email: elft.dpo@nhs.net Telephone: 020 7655 4000

Purpose of the processing

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 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.

Recipient or categories of recipients of the processed data The data will be shared with:
· healthcare professionals and staff in this surgery; · local hospitals; · out of hours services; · diagnostic and treatment centres; · or other organisations involved in the provision of direct care to individual patients.

Rights to object 

You have the right to object to information being shared between those who are providing you with direct care.

· This may affect the care you receive – please speak to the practice. 

· You are not able to object to your name, address and other demographic information being sent to NHS Digital.

· This is necessary if you wish to be registered to receive NHS care.

· You are not able to object when information is legitimately shared for safeguarding reasons. · 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 · HAVERING SAFEGUARDING TEAM: https://www.havering.gov.uk/info/20015/adult_social_care/117/adult_protection_and_safeguarding

· Adult Social Services Safeguarding Adults Team · Telephone: 01708 433 550 · Email: safeguarding_adults_team@havering.gov.uk

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’ policy on the practice website

· We are not aware of any circumstances in which you will have the right to delete correct information from your medical record; although you are free to obtain your own legal advice if you believe there is no lawful purpose for which we hold the information and contact us if you hold a different view. Retention period 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: digital.nhs.uk/article/1202/Records-Management-Code-of-Practice-for-Health-and-Social-Care-2016 or speak to the practice.

Right to complain

You have the right to complain to the Information Commissioner’s Office. If you wish to complain follow this link 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.

How your information is shared so that this practice can meet legal requirements The law requires Dr Poolo’s Surgery – RGMC to share information from your medical records in certain circumstances. Information is shared so that the NHS or Public Health England can, for example:
· plan and manage services; · check that the care being provided is safe; · prevent infectious diseases from spreading.

We will share information with NHS Digital, the Care Quality Commission and local health protection team (or Public Health England) when the law requires us to do so. Please see below for more information. We must also share your information if a court of law orders us to do so.

NHS Digital

· NHS Digital is a national body which has legal responsibilities to collect information about health and social care services.

· It collects information from across the NHS in England and provides reports on how the NHS is performing. These reports help to plan and improve services to patients.

· This practice must comply with the law and will send data to NHS Digital, for example, when it is told to do so by the Secretary of State for Health or NHS England under the Health and Social Care Act 2012.

· More information about NHS Digital and how it uses information can be found at: digital.nhs.uk/home

· NHS Digital sometimes shares names and addresses of patients suspected of committing immigration offences with the Home Office. More information on this can be found here: www.gov.uk/government/publications/information-requests-from-the-home-office-to-nhs-digital 

Public Health

· The law requires us to share data for public health reasons, for example to prevent the spread of infectious diseases or other diseases which threaten the health of the population.

· We will report the relevant information to local health protection team or Public Health England.

· For more information about Public Health England and disease reporting see: www.gov.uk/guidance/notifiable-diseases-and-causative-organisms-how-to-report

Rights to object and the national data opt-out There are very limited rights to object when the law requires information to be shared but government policy allows some rights of objection as set out below.

NHS Digital

· You have the right to object to information being shared with NHS Digital for reasons other than your own direct care.

· This is called a ‘Type 1’ objection – you can ask your practice to apply this code to your record.

· Please note: The ‘Type 1’ objection, however, will no longer be available after 2020.

· This means you will not be able to object to your data being shared with NHS Digital when it is legally required under the Health and Social Care Act 2012. NHS Digital sharing with the Home Office

· There is no right of objection to NHS Digital sharing names and addresses of patients who are suspected of having committed an immigration offence. Public health · Legally information must be shared under public health legislation. This means that you are unable to object.

Care Quality Commission

The CQC regulates health and social care services to ensure that safe care is provided. · The law says that we must report certain serious events to the CQC, for example, when patient safety has been put at risk.

· For more information about the CQC see: www.cqc.org.uk/

· Legally information must be shared when the Care Quality Commission needs it for their regulatory functions. This means that you are unable to object. Court order · Your information must be shared if it ordered by a court. This means that you are unable to object.

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’ policy on the practice website – www.theelmspractice.nhs.uk

· We are not aware of any circumstances in which you will have the right to delete correct information from your medical record; although you are free to obtain your own legal advice if you believe there is no lawful purpose for which we hold the information and contact us if you hold a different view.

Retention period

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: digital.nhs.uk/article/1202/Records-Management-Code-of-Practice-for-Health-and-Social-Care-2016 or speak to the practice.

National screening programmes

· The NHS provides national screening programmes so that certain diseases can be detected at an early stage.

· These screening programmes include bowel cancer, breast cancer, cervical cancer, aortic aneurysms and a diabetic eye screening service.

· The law allows us to share your contact information with Public Health England so that you can be invited to the relevant screening programme.

· More information can be found at: www.gov.uk/topic/population-screening-programmes or speak to the practice. We are required by law to provide you with the following information about how we handle your information in relation to our legal obligations to share data.

Data Controller

contact details Dr Poolo’s Surgery – RGMC 261 Dagenham Rd, Dagenham, Romford RM7 0XR 01708 209220

Data Protection Officer

contact details Chris Kitchener Email: elft.dpo@nhs.net or Call: 020 7655 4000. https://www.elft.nhs.uk/information-about-elft/privacy-and-your-data

Purpose of the processing

· 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 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…’

Recipient or categories of recipients of the processed data

The data will be shared with National Health Screening Services

Rights to object For national screening programmes: you can opt so that you no longer receive an invitation to a screening programme.

See: www.gov.uk/government/publications/opting-out-of-the-nhs-population-screening-programmes Or speak to your practice.

Right to access and correct a) 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’ policy on the practice website b) We are not aware of any circumstances in which you will have the right to delete correct information from your medical record; although you are free to obtain your own legal advice if you believe there is no lawful purpose for which we hold the information and contact us if you hold a different view.

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.

How your information is used for medical research and to measure the quality of care

Medical research Dr Poolo’s Surgery – RGMC shares information from medical records:

 · to support medical research when the law allows us to do so, for example to learn more about why people get ill and what treatments might work best;

 · We will also use your medical records to carry out research within the practice.

 This is important because:
· The use of information from GP medical records is very useful in developing new treatments and medicines;

 · Medical researchers use information from medical records to help answer important questions about illnesses and disease so that improvements can be made to the care and treatment patients receive. We share information with the following medical research organisations with your explicit consent or when the law allows.

 You have the right to object to your identifiable information being used or shared for medical research purposes. Please speak to the practice if you wish to object.

 Checking the quality of care – national clinical audits Dr Poolo’s Surgery – RGMC contributes to national clinical audits so that healthcare can be checked and reviewed.

 · Information from medical records can help doctors and other healthcare workers measure and check the quality of care which is provided to you. · The results of the checks or audits can show where hospitals are doing well and where they need to improve.

 · The results of the checks or audits are used to recommend improvements to patient care. · Data are sent to NHS Digital a national body with legal responsibilities to collect data.

 · The data will include information about you, such as your NHS Number and date of birth and information about your health which is recorded in coded form – for example the code for diabetes or high blood pressure.

 · We will only share your information for national clinical audits or checking purposes when the law allows. · For more information about national clinical audits see the Healthcare Quality Improvements Partnership website: www.hqip.org.uk/ or phone 020 7997 7370.

 · You have the right to object to your identifiable information being shared for national clinical audits. Please contact the practice if you wish to object. We are required by law to provide you with the following information about how we share your information for medical research purposes.

 Data Controller contact details Dr Poolo’s Surgery – RGMC 261 Dagenham Rd, Dagenham, Romford RM7 0XR 01708 209220

 Data Protection Officer contact  details Chris Kitchener Email: elft.dpo@nhs.net or Call: 020 7655 4000. https://www.elft.nhs.uk/information-about-elft/privacy-and-your-data

 Purpose of the processing Medical research and to check the quality of care which is given to patients (this is called national clinical audit).

 Lawful basis for processing 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 Article 9 conditions. Article 9(2)(a) – ‘the data subject has given explicit consent…’

 Recipient or categories of recipients of the processed data For medical research the data will be shared with the patient’s full consent. For national clinical audits which check the quality of care the data will be shared with NHS Digital.

 Rights to object and the national data opt-out You have a right to object under the GDPR and the right to ‘opt-out’ under the national data opt-out model. The national data opt-out model provides an easy way for you to opt-out of: information that identifies you being used or shared for medical research purposes and quality checking or audit purposes. Please contact the practice if you wish to opt-out. 

 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’ policy on the practice website · We are not aware of any circumstances in which you will have the right to delete correct information from your medical record; although you are free to obtain your own legal advice if you believe there is no lawful purpose for which we hold the information and contact us if you hold a different view.

 Retention period 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: digital.nhs.uk/article/1202/Records-Management-Code-of-Practice-for-Health-and-Social-Care-2016 or speak to the practice.

 Right to complain You have the right to complain to the Information Commissioner’s Office. If you wish to complain follow this link ico.org.uk/global/contact-us/ or call the helpline 0303 123 1113

General Practice Transparency Notice for GPES Data for Pandemic Planning and Research (COVID-19)

This practice is supporting vital coronavirus (COVID-19) planning and research by sharing your data with NHS Digital. The health and social care system is facing significant pressures due to the coronavirus (COVID-19) outbreak.

Health and care information is essential to deliver care to individuals, to support health, social care and other public services and to protect public health. Information will also be vital in researching, monitoring, tracking and managing the coronavirus outbreak.

In the current emergency it has become even more important to share health and care information across relevant organisations. This practice is supporting vital coronavirus planning and research by sharing your data with NHS Digital, the national safe haven for health and social care data in England.

Our legal basis for sharing data with NHS Digital NHS Digital has been legally directed to collect and analyse patient data from all GP practices in England to support the coronavirus response for the duration of the outbreak.

NHS Digital will become the controller under the General Data Protection Regulation 2016 (GDPR) of the personal data collected and analysed jointly with the Secretary of State for Health and Social Care, who has directed NHS Digital to collect and analyse this data under the COVID-19 Public Health Directions 2020 (COVID-19 Direction).

All GP practices in England are legally required to share data with NHS Digital for this purpose under the Health and Social Care Act 2012 (2012 Act). More information about this requirement is contained in the data provision notice issued by NHS Digital to GP practices.

Under GDPR our legal basis for sharing this personal data with NHS Digital is Article 6(1)(c) – legal obligation. Our legal basis for sharing personal data relating to health, is Article 9(2)(g) – substantial public interest, for the purposes of NHS Digital exercising its statutory functions under the COVID-19 Direction.

The type of personal data we are sharing with NHS Digital The data being shared with NHS Digital will include information about patients who are currently registered with a GP practice or who have a date of death on or after 1 November 2019 whose record contains coded information relevant to coronavirus planning and research. The data contains NHS Number, postcode, address, surname, forename, sex, and ethnicity, date of birth and date of death for those patients.

It will also include coded health data which is held in your GP record such as details of:
· diagnoses and findings
· medications and other prescribed items
· investigations, tests and results
· treatments and outcomes
· vaccinations and immunisations

How NHS Digital will use and share your data NHS Digital will analyse the data they collect and securely and lawfully share data with other appropriate organisations, including health and care organisations, bodies engaged in disease surveillance and research organisations for coronavirus response purposes only.

These purposes include protecting public health, planning and providing health, social care and public services, identifying coronavirus trends and risks to public health, monitoring and managing the outbreak and carrying out of vital coronavirus research and clinical trials. The British Medical Association, the Royal College of General Practitioners and the National Data Guardian are all supportive of this initiative.

NHS Digital has various legal powers to share data for purposes relating to the coronavirus response. It is also required to share data in certain circumstances set out in the COVID-19 Direction and to share confidential patient information to support the response under a legal notice issued to it by the Secretary of State under the Health Service (Control of Patient Information) Regulations 2002 (COPI Regulations).

Legal notices under the COPI Regulations have also been issued to other health and social care organisations requiring those organisations to process and share confidential patient information to respond to the coronavirus outbreak. Any information used or shared during the outbreak under these legal notices or the COPI Regulations will be limited to the period of the outbreak unless there is another legal basis for organisations to continue to use the information.

Data which is shared by NHS Digital will be subject to robust rules relating to privacy, security and confidentiality and only the minimum amount of data necessary to achieve the coronavirus purpose will be shared. Organisations using your data will also need to have a clear legal basis to do so and will enter into a data sharing agreement with NHS Digital.

Information about the data that NHS Digital shares, including who with and for what purpose will be published in the NHS Digital data release register. For more information about how NHS Digital will use your data please see the NHS Digital Transparency Notice for GP Data for Pandemic Planning and Research (COVID-19).

National Data Opt-Out The application of the National Data Opt-Out to information shared by NHS Digital will be considered on a case by case basis and may or may not apply depending on the specific purposes for which the data is to be used.

This is because during this period of emergency, the National Data Opt-Out will not generally apply where data is used to support the coronavirus outbreak, due to the public interest and legal requirements to share information.

Your rights over your personal data To read more about the health and care information NHS Digital collects, its legal basis for collecting this information and what choices and rights you have in relation to the processing by NHS Digital of your personal data, see:
· the NHS Digital GPES Data for Pandemic Planning and Research (COVID-19) Transparency Notice
· the NHS Digital Coronavirus (COVID-19) Response Transparency Notice
· the NHS Digital General Transparency Notice
· how NHS Digital looks after your health and care information