How To Share Your Health Records With The National Health Service

HOW WE USE YOUR PERSONAL INFORMATION Information Leaflet Your Health. Our Priority.

of 9 Introduction This Leaflet explains why the NHS collects information about you and how it is used, your right to see your health records, and how we keep your personal information confidential. Why we collect information about you Your doctor, nurse or midwife and the team of health professionals caring for you keep records about your treatment and care both on paper and electronically. These include: Personal details about you, such as name, address, date of birth, ethnicity and religion, NHS number and next of kin; Contact details, including mobile telephone number, contact we have with you e.g. hospital admissions, outpatients/clinic appointments and home visits; Notes and reports by staff about your health, GP details etc; Details and records of your treatment and care; Results of investigations, x-rays, laboratory tests etc; Relevant information about people that care for you and know you well Basic details about associated people e.g. children, partners, carers, relatives etc How is the information used? To provide you with care and treatment, both now and in the future, ensuring that appropriate information is available to all those who treat you medically and care for you professionally To ensure your care is safe and effective To support you in managing your own care and in working with health and care professionals to support no decision about you without you To look after the health of the general public, using statistical information To manage and plan the work of the NHS To help staff review the care they provide e.g. clinical audit To train and educate staff (you can choose whether or not to be involved personally) Some medical files are needed to teach student clinicians about rare cases. Without such materials, new doctors and nurses would not be properly prepared to treat you. Clinical placements for students commonly take place within the NHS. Students, such as student nurses, medical students, social work students or health care cadets, could be receiving training in the service that is caring for you. This may be when you are an inpatient, or in a community setting such as a day hospital and even, in some cases, when you are being visited by health or social care staff at home. If staff would like a student to be present they will always ask your permission before that meeting or episode of treatment. If you do not want a student to be present you may refuse without the treatment or care you receive being affected. Occasionally, for assessment purposes, students may request that their supervisor be present and, again, you may refuse if this makes you feel uncomfortable.

of 9 To carry out research approved by a Research Ethics Committee. Before any of your personal information is used for research you will be given information about the study and asked to sign a consent form to confirm you would like to take part. You will not be identified in any published results without your agreement. To Investigate any complaints, legal claims or serious untoward incidents NHS Care Record Guarantee The Care Record Guarantee is our commitment that we will use records about you in ways that respect your rights and promote your health and wellbeing. Copies of the full document can be obtained from the Trust s website at or www.nigb.nhs.uk. Hard copies can also be requested from the Trust or the National Information Governance Board, 7th Floor, New King's Beam House, 22 Upper Ground, London, SE1 9BW. We will not disclose your information to a third party without your permission unless there are exceptional circumstances, such as when the health and safety of others is at risk or if the law requires us to pass on information. This includes notifying the register of a birth or death, in the case of certain infectious diseases to protect the health of the general public and in child protection cases, or where a formal court order has been issued. How we protect your information Your personal information is safeguarded by the Date Protection Act 1998. The sensitivity of patient information is well understood within the NHS (all staff are given training on their duty of confidentiality to you). We keep paper and electronic records securely to prevent unauthorised access in line with current legislation. Managing the information we hold We need to be able to move electronic information between the separate systems that provide information to support your care and the care processes. Data is also extracted and processed to support the operation of the services and monitoring the delivery and management of the services. Some of this processing may be carried out by 3 rd parties, subject to adherence to strict standards of information security and compliance with the Data Protection Act. Your NHS number, keep it safe Every person registered with the NHS in England and Wales has their own unique NHS Number. It is made up of 10 digits for example 123 456 7890. Everyone needs to use the NHS Number to identify you correctly. It is an important step towards improving the safety of your healthcare.

of 9 Always bring your NHS number with you to all hospital appointments or quote it if you need to telephone the hospital for any enquires. This will allow staff to check that they have the right patient details by checking this against your NHS number. To improve safety and accuracy always check your NHS Number on correspondence the NHS sends to you. If you do not know your NHS number, contact your GP. You may be asked for proof of identity, for example a passport or other form of identity; this is to protect your privacy. Once you have obtained your NHS Number write it down and keep it safe When information may be shared, and with whom We will only ever share your information if it is in the best interests for your care. We will not disclose any information that identifies you to anyone outside of your direct care team 1 without your express permission, unless there are exceptional circumstances such as when there is serious risk of harm to yourself or others or where the law requires it. Who we may share your information with: Direct care organisations: Other Hospitals GPs Ambulance Service Social care You will be asked for your explicit consent for identifiable information to be shared with noncare organisations which will be subject to strict agreement about how it will be used, for example: Housing departments Education services Voluntary services Sure start teams The police Government departments Private Sector Providers working with the NHS There may be circumstances where the reasons for disclosure are so important that they override the obligation of confidentiality e.g. to prevent someone from being seriously harmed. Disclosure may also be required by Court Order or under an Act of Parliament, i.e. there is a statutory or other legal basis for the disclosure. The advice of specialist staff e.g. Caldicott 1 Direct care team is the term used to include clinical care, social care and public health activity relating to individuals. It also includes activity such as audit and management of untoward incidents where these are carried out by people who have a legitimate relationship for that person s care. The direct care team is made up of registered and regulated professionals with a duty of confidentiality and an obligation to use information both legally and effectively. They are answerable to regulatory bodies such as the General Medical Council, Nursing & Midwifery Council and Health & Care Professions Council. (Caldicott Review, 2013, page 38)

of 9 Guardian is also sought prior to making disclosures in the public interest or where a Court Order or statutory basis is provided as justification Your Information may also be used by the Department of Health for secondary purposes such as service development analysis and national statistical research. However safety and security measures will be incorporated to pseudonymise 2 and anonymise 3 patient identifiable data before it is stored and made available for secondary uses. If you wish for your information not to be used for this purpose, please let the service know or write to the Trust s: Patient & Customer Services Team Stockport NHS Foundation Trust Stockport SK2 7JE Section 251 Disclosures may be permitted under Section 251 of the NHS Act 2006. This allows the Secretary of State for Health to set aside the common law duty of confidentiality in special circumstances. This has to be to improve patient care or in the public interest such as for important medical research. Applications for approval to use Section 251 are considered by the Confidentiality Advisory Group (CAG) who will advise whether there is sufficient justification to access the request confidential patient information. Examples of this, used in the short-term until other measures can be put in place, are risk stratification and invoice validation. How you can access your health record The Data Protection Act gives you a right to access the information we hold about you on our records. Your request must be made in writing to the Medico-Legal Department of the Trust. For information from another Hospital or your GP you should contact them directly. An application form is available from our website or from the Patient & Customer Services Department by telephoning 0161 419 5425; You will need to give adequate information (for example full name, address, date of birth, NHS number etc) so that your identity can be verified and your records located; If you have any difficulty in completing an application form, please contact the Patient & Customers Services Department for assistance; 2 Pseudonymise: your data will be given a unique number that will be used to make sure you cannot be identified outside of your clinical care team 3 Anonymise: any personal information will be removed from your data before it is shared so you cannot be identified

of 9 If you are requesting a copy of your medical records a charge applies, this will be a maximum of 50.00 for manual records, or 10.00 for records entirely computer based. Please see our website for further information. We aim to respond promptly and are required to do so within 40 days of receiving your request. We may refuse access where: The health professional in charge of your care believes it may be mentally or physically harmful to you or another person to see the contents of your records; If by providing access, we would reveal information which relates to and identifies another person unless that person has given consent. This would not usually include health professionals. We will normally be able to provide your records with any such information removed and we would usually inform you if this is the case. If you think any of the information is inaccurate or incomplete, please let us know. To apply for access to your records, you should contact: Patient & Customer Services Medico Legal Support Team Stockport NHS Foundation Trust Stockport SK2 7JE Telephone: 0161 419 5425 Snt-tr.medicolegal@nhs.net It will help us if you can state which hospital/clinic you attended and the approximate dates and type of treatment for which you want to see the record. You must apply in writing, giving your name, address, date of birth and, if you have it, your NHS number. Say that you are applying for access to your health records and please allow up to 40 days for the processing of your application. For providing copies of your medical (paper) records, or x-ray films you will be charged a fee, depending on the work involved. You will be advised of the amount of this fee by the Medico Legal team, before any work is undertaken. Keeping information up to date If you consider that any part of the information held in your record is inaccurate, you can apply to have this corrected. If we agree that the information is incorrect, the alteration will be made. If we are not satisfied that the information is incorrect, a note will be made of the information you consider to be inaccurate. You will be given a copy of either the correction or the note.

of 9 What else? You can have a say in how the NHS uses information about you. If you do not wish personal data to be used or shared in the way that is described in this leaflet, please discuss the matter with us. You have the right to request that your confidential information is not used beyond your own care and treatment and to have your objections considered and, where your wishes cannot be followed, to be told the reasons why including the legal basis 4 Outpatient reminders and your feedback on services via Landline or Mobile SMS/Text The Trust has a significant number of patients who fail to attend their Outpatient appointment. This impacts on the Trust from a financial point of view and adversely affects the access times. Appointment and demographic data may be used to remind you of your appointments. We may use the services of an approved third party If you would like to opt out of this service please inform the Appointment Booking Centre by telephoning 0161 483 1010 or the Patient & Customer Services Department 0161 419 5678. In addition, some services may contact you by landline/sms/text for appointment reminders and for requesting feedback on the service offered and on your care and treatment, for example under the Friends & Family initiative. This information is voluntary on the part of the patient and is provided via the Trust s internet site or by completion of a postcard or you may receive a phone call/text. Surveys are also conducted anonymously by volunteers using ipads. The Trust will ensure that mobile phone information is only used under the same safeguards that we apply to all our patient information. We may use the services of approved third party providers to deliver these services on behalf of the Trust and is subject to strict safeguards in accordance with the Data Protection Act. Copying letters to patients Patients now have a right to a copy of any letter written about them from one healthcare professional to another. If you would like to opt out of this service, please inform the doctor during your appointment. Notification The Data Protection Act 1998 requires organisations to lodge a notification with the Information Commissioner to describe the purposes for which they process personal information. The details are publicly available from the Information Commissioner s office at www.ico.gov.uk or by mail to: Information Commissioners Office Wycliffe House, Water Lane 4 NHS Constitution for England section 3a (26 March 2013)

of 9 Wilmslow, Cheshire SK9 5AF Telephone: 01625 545745 Who is the Data Controller? The Data Controller, responsible for keeping your information confidential is: Stockport NHS Foundation Trust Poplar Grove Stockport Cheshire SK2 7JE Telephone: 0161 483 1010 Website: Please address any queries to the Information Governance Department. Freedom of Information Act If you want any information about the organisation, which is not personal data, please write to us or email FOI@Stockport.nhs.uk Contact us If you need further information, please don t hesitate to contact the Information Governance team: Information Governance 1 st Floor, Cedar House Poplar Gove Stockport. SK2 7JE Tel: 0161 419 5295/4364 Information.Governance@stockport.nhs.uk The Trust may contact you to help us gain feedback that would inform service improvements, and this will be via the service you attended.

of 9 If you would like this leaflet in a different format, for example, in large print, or on audiotape, or for people with learning disabilities, please contact: Patient and Customer Services, Poplar Suite,. Tel: 0161 419 5678. Email: PCS@stockport.nhs.uk. Our smoke free policy Smoking is not allowed anywhere on our sites. Please read our leaflet 'Policy on Smoke Free NHS Premises' to find out more. Leaflet number GEN03 Publication date August 2015 Review date August 2017 Department Information Governance Location