Policy. Information Steering Group. Version Author Date Reason for review 0.0 Andrew Thomas July Neil Taylor August 2013

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1 Policy Author(s) Andrew Thomas Version 1.0 Version Date 21 August 2013 Implementation/approval Date 14 August 2013 Review Date August 2014 Review Body Information Steering Group Policy Reference Number 015 Version Author Date Reason for review 0.0 Andrew Thomas July Neil Taylor August 2013 Formatting Adjustments to match CCG Policy on Polices 0.2 Neil Taylor August 2013 Minor adjustments from IG Steering Group 0.3 Neil Taylor September 2013 Minor adjustments from Policy Review Group 1.0 September 2013 Final Policy Page 1 of 18

2 Contents Page 1.0 Introduction Policy statement and aim Objectives Scope of Policy Governance Roles and responsibilities Capacity Allocation Remote working Change management Disciplinary measures Personal Freedom of Information and Subject Access Requests Electronic Mail Procedures Management Retention Staff Absence Forwarding Distribution Subject Heading Attachments Etiquette Spam Malicious Software Misuse Formatting Further Information Personal Confidential Data (PCD) Monitoring Compliance with this Policy Monitoring of compliance Non Compliance Implementation and dissemination of document Training Requirements Latest Version Associated Documents Appendices Appendix 1 Equality & Equity Impact Assessment Checklist Appendix 2 Consultation History Appendix 3 Security & Legal Obligations Appendix 4 Out of Office Template Appendix 5 Standard Signature Templates Policy Page 2 of 18

3 1.0 Introduction NHS Greenwich Clinical Commissioning Group (CCG) will provide its staff with access to the use of NHSMail (The System) for use wholly in connection with the Greenwich legitimate business interest. This policy, which governs use of the system, will be sent to all new users when their account is set up and to all users when the policy is amended. Failure to comply with this policy could result in disciplinary action being taken. This policy applies to all directly employed CCG staff, including Governing body members, syndicate and Clinical and non-clinical leads. GP and Dental practices in the Greenwich geographic area are also subject to this policy when capacity allocation is made. GP and Dental practices within the CCG catchment area are encouraged to implement their own policy and they are free to model their policy on this if they wish. In this case the CCG will waive their copyright on this policy Policy statement and aim To identify users security and operational obligations in respect of the use of the CCG system Objectives The objectives in implementing this policy are: To improve general communications within the CCG. To reduce significantly the need for paper exchange, provide an opportunity to reduce the amount of paper consumed and reduce the risk of breaches of confidentiality. To reduce the need for extensive photocopying of documents To provide a mechanism for more timely communications To reduce the time and resources spent on unsuccessful telephone calls. To provide an automatic audit trail of all internal electronic communications. To manage the system capacity of the CCG and wider sponsored organisations. Policy Page 3 of 18

4 2.0 Scope of Policy This policy is applicable to: All use held or processed by the CCG and its constituent statutory bodies. All capacity allocation used by GP and dental practices and its constituent statutory bodies in the Greenwich geographic area or Greenwich sponsored organisations. All permanent, contract or temporary personnel and all third parties who have access to CCG premises, systems or information. Any reference to staff within this document also refers to those working on behalf of the CCG on a temporary, contractual or voluntary basis This document will refer to information as a term that will encompass data. The term information is understood as details that can be understood independently, for example an . Data to information that requires the context of a system to be understood, for example SUS data. 3.0 Governance 3.01 Roles and responsibilities All new members of staff are required to have a CCG NHSmail address. This will be provided by the CCG and be allocated within the CCG s NHSmail container. Authorisation of the creation of the address will be via the ICT helpdesk and line manager Capacity Allocation There is a finite capacity allocation available to NHS organisations and the Organisations it sponsors. The breakdown for this is: Platinum Service (2GB) 2% Gold Service (1GB) 3% Silver Service (400mb) 80% All other individual and generic accounts Bronze Service (100mb) 15% Mainly used for dummy accounts used in the automated process of electronic data transfer. Within each organisation the average capacity can not be exceeded and the organisation will not be able to allocate new addresses. In the current CCG structure covering 63 individual accounts and 13 Generic accounts this would equate to: Platinum Service (2GB) 1 individual Gold Service (1GB) 2 individuals Silver Service (400mb) 53 individuals Bronze Service (100mb) 10 individuals Policy Page 4 of 18

5 All individual users within the CCG container will be allocated 400mb as a minimum. Platinum and Gold service accounts will not be offered to individuals, but will be reviewed on an annual basis Remote working With effective archiving, rule processing and the use of generic accounts the CCG and individuals can keep within an individual 400mb account allocation. To help with remote working, individuals should be aware of sending large files to multiple users and think if there is another way of distributing the data/information. A generic can be provided on request to ICT Helpdesk to every directorate/team to better utilise the distribution of large files being sent to many users Change management Process of change that encompasses the use of patient data must consider the issue of consent and provision of information to patients. More information is available through the IG Change Protocol 3.04 Disciplinary measures Staff must comply with the standards and governance around consent to process information as detailed in this policy, supporting protocols and procedures. Failure to do so can result in disciplinary action. All staff are reminded that this policy covers several aspects of legal compliance that as individuals they are responsible for. Failure to maintain these standards can result in criminal proceedings against the individual. These include but are not limited to: Data Protection Act 1998 Freedom of Information Act 2000 Computer Misuse Act 1990 Common law duty of confidentiality For a full list of relevant legislation and guidance see the Information Governance Management Framework Personal The use of personal addresses for business use is not permitted. This covers all addresses outside of the NHSmail container. Examples of non-nhs accounts include Hotmail, Yahoo, AOL, and services provided by internet service providers. NHSmail is available on N3 or over the web. There should be no need for staff to use personal for business use even when away from the designated work base Freedom of Information and Subject Access Requests All usage is auditable and also under the Freedom of Information Act (FoI) and Subject Access Request to Health Records (SAR) content of the system and Policy Page 5 of 18

6 associated archiving files (.pst,.ost as examples) can be requested and disclosed. All requests under FoI and SAR will follow the CCG s polices, protocols and procedures. 4.0 Electronic Mail Procedures Management All users should check their inbox regularly (preferably at least twice per day i.e. once in the morning and once in the afternoon). Please delete s as soon as they are not required. The storage space on the system is a shared resource, and is finite; therefore deleting unnecessary will help the system run efficiently Retention communications should, wherever possible, be stored in a user s own mail folders and archived or deleted regularly. Hard-copy print outs may be necessary for some filing purposes, but these should be minimised Staff Absence Planned In the case of planned absence from work users should set an automatic response (Example in Appendix 4) to ensure that the sender of the message is informed that s will not be read or acted upon until the recipient returns. Unplanned In cases of unplanned long term absence (e.g. through sickness), line managers can ensure that the for absent staff can be read and dealt with by another staff member through the use of proxy access or forwarding. This can be facilitated through the ICT helpdesk Forwarding Users must not automatically forward from their CCG account or send confidential or sensitive CCG information to non-nhs accounts. Examples of non-nhs accounts include Hotmail, Yahoo, AOL, and services provided by internet service providers Distribution As distribution lists are easy to use, there is a tendency to copy lots of people in on every message leading to frustration over unnecessary communications. If distribution lists are set up by individuals they should be regularly reviewed and edited to ensure they remain relevant and up-to-date. Only send s to those concerned by its content Subject Heading All communications should be headed with a meaningful title to allow recipients to browse through note headings before opening. Policy Page 6 of 18

7 4.07 Attachments Where access to a shared network area is not available to both sender and recipient(s), documents and spreadsheets should always be sent as an attachment to an . This method of communication is very much encouraged as an alternative to sending paper copies. However, try to avoid sending excessively large attachments via as NHSmail has a limit of 20mb. When it is absolutely necessary to send a large attachment (for business purposes only), please keep the number of recipients to a minimum and the use of Secure File Transfer protocol may be more appropriate Etiquette When sending s externally, it is important to remember the following etiquette: Typing in capitals could be considered as shouting. Formatting in messages (i.e. bold, italics) may not be retained Try not to send messages that are too long (more than a thousand lines) as some systems cannot cope with messages this long. When responding to a message, include part of the original so the recipient will know the context. The absence of body language makes for occasional misunderstandings, so if you use humour or sarcasm, make sure it is labelled as such. Be aware of any implications that an might have before transmission. Certain content might be interpreted in a way that was not intended if due consideration is not given to the wording. Never send any content that can be interpreted as offensive in any way Spam Giving your CCG address to organisations on the Internet may give rise to you receiving unsolicited s (often called spam). The quantity of these s can quickly become excessive, so please be cautious when giving your address to others Malicious Software The use of to spread software viruses has increased dramatically in recent times. Please be cautious when reading messages from unknown senders and running unusual attachments. If you are unsure of the safety of a particular message, delete it without reading it Misuse Misuse of in any way may result in disciplinary action being taken. Examples of misuse would include harassment, disclosing sensitive or confidential information, sending obscene or offensive materials, sending defamatory material or use of the CCG system for excessive private use (i.e. other than that detailed in 4.02) or personal gain. Staff should not send internal or external s consisting of jokes, offensive material or chain letters. Policy Page 7 of 18

8 4.12 Formatting Signature The CCG have a standard signature template for New and Forward/Replies of s. Please reference Appendix 5 Body o Do not use background templates, these may not be retained when sending onto other organisations or applications. o When creating a new use Font: Arial, Size: 11, colour: Black o When creating a reply or forward use Font: Arial, Size: 11, colour: Dark Blue 4.13 Further Information For further information and advice on using and managing your ; please contact the ICT HelpDesk. 5.0 Personal Confidential Data (PCD) All users must familiarise themselves with the legal obligations as they relate to ing PCD (see notes under Legal Obligations for further guidance). This applies equally to information regarding patients or staff. The CCG system is secure from external access and as such PCD can be ed within the NHSmail environment. It is however good practice to anonymise any data or use the minimum information necessary to identify the person. This may for example mean using initials or an identification number for patients, instead of a full name. Always check before sending PCD outside the CCG. Is it necessary? addresses should be double checked before sending. s containing PCD should only be sent to those recipients who have a need to know and should not be circulated to a wider audience unless this can justified. Sending PCD is the responsibility of the sender at all times and as such due care and observance of CCG and legal obligations must be undertaken. This equally applies to s that are forwarded on to a third party the forwarder takes responsibility for following the due processes. All s that contain PCD should be marked as Confidential. No PCD should be entered into the subject line of the . All flows of PCD should be recorded and assessed or approved by the Information Governance Lead and SIRO. Safe haven procedures must be used when sending confidential or sensitive information by . If staff need to communicate with social services, quoting patient identifiable information, then they should send the using their nhs.net account AND use the suffix cjsm.net at the end of the recipient s Address. For Policy Page 8 of 18

9 example: o Log on to NHS Mail account in the normal way. o Compose , using the Royal Borough of Greenwich address plus the suffix cjsm.net, e.g. somebody@royalgreenwich.gov.uk.cjsm.net o When sent, this will pass over the cjsm secure network and so can be treated as secure. o This method can be used for secure transfers for any other gov.uk addresses. Confidential or sensitive CCG information must not be accessed from non-nhs equipment. (Arrangements for working outside of this policy require prior approval from the manager who should seek advice from the Information Governance Lead). 6.0 Monitoring Compliance with this Policy 6.01 Monitoring of compliance Measurable Monitoring/Audit Frequency Policy of Objective monitoring Ensure standardised Format of Signature across Organisation Audit by Received s and incident reporting Quarterly Responsibility for performing the monitoring Information Governance Lead Monitoring reported to which groups/committees, including responsibility for reviewing action plans Information Governance Steering Group 6.02 Non Compliance Noncompliance with this Policy by staff will be brought to the attention of the Information Governance Steering Group. 7.0 Implementation and dissemination of document The Policy, once approved by the CCG s governing body, or delegated group, will be shared with all staff through the all staff , updated on the intranet, and shared with the CCG s Management Board. A team briefing will be provided to support this dissemination. 8.0 Training Requirements Training will be carried out for this policy under the Information Governance Training Needs Assessment. Policy Page 9 of 18

10 9.0 Latest Version The audience of this document should be aware that a physical copy may not be the latest version. The latest version, which supersedes all previous versions, is available on the CCG Internet and Intranet Associated Documents As a new organisation, the CCG is still developing a broad range of policies, protocols and procedures, which will be subject to further updates and additions. Related CCG policies, protocols and procedures currently include: Consent to use PCD Policy Policy Information Governance Policy Internet Policy Mobile Device Policy Records Management Policy Acceptable Use Protocol Confidentiality Code of Conduct Protocol Freedom of Information Protocol Information Sharing Protocol Information Lifecycle Protocol Pseudonymisation Protocol Safe Haven Protocol Confidentiality Audit Procedure Subject Access to Health Records Procedure Supporting documentation also includes: Information Governance Management Framework Information Communication and Technology Framework Information Governance Strategy Information Governance Acronyms Document Information Governance Roles & Responsibilities Document Information Governance Steering Group Terms of Reference Information Governance Training Needs Assessment 11.0 Appendices Appendix 1 Equality Impact Assessment Checklist Appendix 2 Consultation history Appendix 3 Security & Legal Obligations Appendix 4 Out of Office Template Appendix 5 Standard Signature Templates Policy Page 10 of 18

11 Appendix 1 Equality & Equity Impact Assessment Checklist This is a checklist to ensure relevant equality and equity aspects of proposals have been addressed either in the main body of the document or in a separate equality & equity impact assessment (EEIA)/ equality analysis. It is not a substitute for an EEIA which is required unless it can be shown that a proposal has no capacity to influence equality. The checklist is to enable the policy lead and the relevant committee to see whether an EEIA is required and to give assurance that the proposals will be legal, fair and equitable. The word proposal is a generic term for any policy, procedure or strategy that requires assessment. Challenge questions Yes/No What positive or negative impact do you assess there may be? 1. Does the proposal affect one group more or less favourably than another on the basis of: Race No Pregnancy and Maternity No Sex No Gender and Gender Re-Assignment No Marriage or Civil Partnership No Religion or belief No Sexual orientation (including lesbian, gay bisexual and transgender people) No Age No Disability (including learning disabilities, physical disability, sensory impairment and mental health problems) No 2. Will the proposal have an impact on lifestyle? (e.g. diet and nutrition, exercise, physical activity, substance use, risk taking behaviour, education and learning) 3. Will the proposal have an impact on social environment? (e.g. social status, employment (whether paid or not), social/family support, stress, income) 4. Will the proposal have an impact on physical environment? (e.g. living conditions, working conditions, pollution or climate change, accidental injury, public safety, transmission of infectious disease) No No No 5. Will the proposal affect access to or experience of services? (e.g. Health Care, Transport, Social Services, Housing Services, Education) Document Author No Equalities Lead (Carol Berry) Signature: Signature: Policy Page 11 of 18

12 Appendix 2 Consultation History Stakeholders Name Area of expertise Date sent Date received Comments Changes made Policy Page 12 of 18

13 Appendix 3 Security & Legal Obligations 1. Ownership Ownership of all messages, attachments and files remain the property of the CCG and as such are open to scrutiny at any time. The CSU IT Manager can be authorised by a director to audit any transmissions. This authority must be given in writing. This is consistent with the Employment Practices Data Protection Code (2003) ( and the Human Rights Act Surveillance The CCG can open and read staff s in accordance with the Regulation of Investigatory Powers Act 2000 (RIPA 2000) and the Telecommunications (Lawful Business Practice, Interception of Communications) Regulations This means that the CCG can intercept a communication or in the course of its transmission in order to: establish the existence of facts or, ascertain compliance with regulatory or self-regulatory practices or procedures which are applicable to the system controller in the carrying out of his business or applicable to another person in the carrying out of his business where that person is supervised by the system controller in respect of those practices or procedures, or ascertain or demonstrate the standards which are achieved or ought to be achieved by persons using the system in the course of their duties, or in the interest of national security, or for the purpose of preventing or detecting crime or, for the purpose of investigating or detecting the unauthorised use of that or any other communication system. The CCG will make all reasonable attempts to inform every employee that uses the system that communications transmitted in this way may be intercepted. The CCG will not open any marked Private & Confidential or read the content of the unless it is necessary in the interests of: National security Public safety Economic well-being of the country The prevention of disorder or crime The protection of health or morals The protection of the rights and freedoms of others If it is suspected that the Private and Confidential marking is being used to conceal breaches of any of Greenwich CCG s policies. When intercepting employees use of s because of any of the reasons specified above the CCG s actions will be proportionate to achieving its legitimate aim or aims. In all cases the interception will be authorised in writing by a Director. Policy Page 13 of 18

14 3. Legal Obligations Users are reminded about their obligations under the following Acts: The Data Protection Act 1998 This Act governs the use and disclosure of personal information and is very clear in restricting access, sharing and disclosure of personal information on a need to know basis. Personal information regarding staff or patients must not be ed outside the CCG unless anonymised. Said information can be ed within the CCG as the network is secure from external access but due consideration must be given to the principle of need to know. As such identifiable information should only be sent to the intended recipient and should be anonymised where possible i.e. by supplying a pseudonym rather than name and contact details. Under the Act all patient identifiable information can be accessed, including s and calendar file notes if requested therefore the sender of such s must be prepared for the content to be printed off and recorded in the clinical record. Personal information can only be passed on with the express consent of the person concerned except in certain conditions. Further clarification of how the Data Protection Act applies to transmission of information can be sought from the CCG Information Governance Lead The Computer Misuse Act 1990 It is a criminal offence to carry out deliberate acts designed to damage systems or data, or for a user to attempt to gain access to data that they do not have permission to access. The Copyright, Designs & Patents Act 1988 This act expressly forbids the copying of programs and associated files without the purchase of an appropriate licence. The Human Rights Act 1998 Article 8 of which concerns the right to privacy. The CCG and its employees also have responsibilities under the Caldicott Guidelines, regarding the protection and use of patient information. For further advice on these, please contact the CCG Caldicott Guardian. Any messages sent via are classed as the printed word and therefore the laws of libel, etc may still apply. Failure to abide by these obligations may result in disciplinary action. 4. Disclosure Staff should note that content of s can be used as evidence in legal cases so no information regarding any staff member, patient or other person should be entered into an unless there is full evidence to justify the statement. This evidence should be retained. This applies even if the has been deleted as the CCG can be legally required to produce retained back-ups of all s, including deleted ones. Policy Page 14 of 18

15 5. Security Every user must have unique passwords for all the systems to which they have access. NHSmail provide the admin and support for NHSmail with local organisation administrators (LOA s) providing capacity and admin functions at a local level. Policy Page 15 of 18

16 Appendix 4 Out of Office Template 1. Standard Out of Office Many Thanks for your I am currently out of the office and will return ##/##/####. If your is relating to X please redirect your to:.. If your is relating to Y please redirect your to:.. Your Name Your Job Title/Directorate NHS Greenwich CCG Policy Page 16 of 18

17 Appendix 5 Standard Signature Templates 1. Desktop PC s and NHSMail Web Access All New s should have the following signature: Your Name Your Job Title/Directorate NHS Greenwich Clinical Commissioning Group Greenwich Park Street Greenwich London SE10 9LR Your address Tel: XXXX (Internal Extension: 38XXXX) Work Mobile: 07XXX XXXXXX (IF YOU HAVE ONE) Web: Working days: (IF APPLICABLE) Font: Arial Size: 11 Font Style: Bold Font Colour: Black Font: Arial Size: 11 Font Style: Bold/regular Font Colour: Dark Blue Lighter 40% Hyperlinks should be available Image is available from the communications team Policy Page 17 of 18

18 All Replies and Forwards should have the following Signature: Your Name Your Job Title/Directorate NHS Greenwich CCG Tel: XXXX (Internal Extension: 38XXXX) Work Mobile: 07XXX XXXXXX (IF YOU HAVE ONE) Font: Arial Size: 11 Font Style: Bold Font Colour: Dark Blue Font: Arial Size: 11 Font Style: Bold Font Colour: Dark Blue Lighter 40% 2. ipad and iphones All s should have the following signature: Your Name Your Job Title/Directorate NHS Greenwich CCG Tel: XXXX (Internal Extension: 38XXXX) Work Mobile: 07XXX XXXXXX (IF YOU HAVE ONE) Sent from a Mobile Device Font: Arial Size: 11 Font Style: Bold Font Colour: Dark Blue Font: Arial Size: 11 Font Style: Bold Font Colour: Dark Blue Lighter 40% Policy Page 18 of 18