Information Governance Policy

Information Governance Policy

Information Governance Policy Issue Date: June 2014 Document Number: POL_1008 Prepared by: Information Governance Senior Manager Insert heading depending on Insert line heading length; please depending delete other on line length; please delete Insert cover heading options depending once you other cover options once on have line length; chosen please one. 20pt delete you have chosen one. 20pt other cover options once you have chosen one. 20pt Status: Approved Next Review Date: March 2017 Page 2 of 19

Information Reader Box Directorate Medical Nursing Patients & Information Finance Operations Commissioning Development Policy Transformation & Corporate Operations Purpose Tools Guidance Resources Consultations Publications Gateway Reference 00148 Document Purpose Document Name Publication Date June 2014 Target Audience Additional Circulation List Description Cross Reference Policy and High Level Procedures All NHS England staff n/a Policy and high level procedures for Information Governance n/a Superseded Document version 1.1 Action Required Timing/Deadlines Author To Note n/a Carol Mitchell, Information Governance Senior Manager Quarry House LEEDS Tel: 01132545935 E-mail: carol.mitchell5@nhs.net Status: Approved Next Review Date: March 2017 Page 3 of 19

Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet. Status: Approved Next Review Date: March 2017 Page 4 of 19

Contents Information Reader Box... 3 Document Status... 4 1. Introduction... 6 2. Scope... 7 3. Roles and Responsibilities... 8 4. Framework... 12 5. Information Governance and Records Management Group... 14 6. Information Governance Team... 14 7. Distribution and Implementation... 15 8. Monitoring... 16 9. Equality Impact Assessment... 16 10. Associated Documents... 17 Version Control Tracker... 18 Status: Approved Next Review Date: March 2017 Page 5 of 19

1. Introduction 1.1. The role of NHS England is to commission healthcare, both directly and indirectly, so that valuable public resources secure the best possible outcomes for patients. In doing so, NHS England will seek to meet the objectives prescribed in the Mandate and to uphold the NHS Constitution. This policy is important because it will help the people who work for the NHS England understand how to look after the information they need to do their jobs, and to protect this information on behalf of patients. 1.2. The purpose of this document is to provide guidance to all NHS England staff, including those working for Commissioning Support Units (CSUs), on Information Governance. 1.3. Information Governance is a framework for handling personal information in a confidential and secure manner to appropriate ethical and quality standards in a modern health service. It provides a consistent way for employees to deal with the many different information handling requirements including: Information Governance Management. Clinical Information assurance for Safe Patient Care. Confidentiality and Data Protection assurance. Corporate Information assurance. Information Security assurance. and Secondary use assurance. 1.4. The aims of this document are: To maximise the value of organisational assets by ensuring that data is: Held securely and confidentially. Obtained fairly and lawfully. Recorded accurately and reliably. Used effectively and ethically, and Shared and disclosed appropriately and lawfully. Status: Approved Next Review Date: March 2017 Page 6 of 19

2. Scope To protect the organisation s information assets from all threats, whether internal or external, deliberate or accidental. NHS England will ensure: Information will be protected against unauthorised access. Confidentiality of information will be assured. Integrity of information will be maintained. Information will be supported by the highest quality data. Regulatory and legislative requirements will be met. Business continuity plans will be produced, maintained and tested. Information security training will be available to all staff, and All breaches of information security, actual or suspected, will be reported to, and investigated by the Information Governance Senior Manager. 2.1 Staff within the Scope of this Document Staff of the following NHS England areas are within the scope of this document: National Teams; Regional Teams; Area Teams; All Commissioning Support Units; NHSIQ; Leadership Academy; Sustainable Development Unit; Strategic Clinical Networks; Clinical Senates; and, Staff working in or on behalf of NHS England (this includes contractors, temporary staff, secondees and all permanent employees). Status: Approved Next Review Date: March 2017 Page 7 of 19

3. Roles and Responsibilities 3.1 Chief Executive 3.1.1 Overall accountability for procedural documents across the organisation lies with the Chief Executive who has overall responsibility for establishing and maintaining an effective document management system, for meeting all statutory requirements and adhering to guidance issued in respect of procedural documents. 3.2 Caldicott Guardian 3.2.1 The NHS England Medical Director has been appointed Caldicott Guardian. Who will: Ensure that NHS England satisfies the highest practical standards for handling patient identifiable information. Facilitate and enable appropriate information sharing and make decisions on behalf of NHS England following advice on options for lawful and ethical processing of information, in particular in relation to disclosures. Represent and champion Information Governance requirements and issues at Board level. Ensure that confidentiality issues are appropriately reflected in organisational strategies, policies and working procedures for staff, and Oversee all arrangements, protocols and procedures where confidential patient information may be shared with external bodies both within, and outside, the NHS. 3.2.2 Caldicott Guardians have be appointed in Region / Area Teams and in all hosted bodies i.e. Commissioning Support Units. These Caldicott Guardians will be accountable to the Medical Director as Senior Responsible Caldicott Guardian for NHS England as a whole. Status: Approved Next Review Date: March 2017 Page 8 of 19

3.3 Senior Information Risk Owner (SIRO) 3.3.1 The NHS England National Director, Transformation & Corporate Operations has been nominated as Senior Information Risk Owner (SIRO). Who will: Take overall ownership of the organisation s Information Risk Policy. Act as champion for information risk on the Board and provide written advice to the Accounting Officer on the content of the organisation s statement of internal control in regard to information risk. Understand how the strategic business goals of NHS England and how other NHS organisations business goals may be impacted by information risks, and how those risks may be managed. Implement and lead the NHS Information Governance Risk Assessment and Management processes within NHS England; Advise the Board on the effectiveness of information risk management across the NHS England, and Receive training as necessary to ensure they remain effective in their role as SIRO. 3.3.2 SIRO s will also be appointed in region teams and in all hosted bodies i.e. CSUs. These SIROs will be accountable to the National Director: Transformation & Corporate Operations as Senior Responsible SIRO for NHS England as a whole. 3.4 Information Asset Owners 3.4.1 Information Asset Owners (IAO) will: Lead and foster a culture that values, protects and uses information for the benefit of patients. Status: Approved Next Review Date: March 2017 Page 9 of 19

Know what information comprises or is associated with the asset, and understands the nature and justification of information flows to and from the asset. Know who has access to the asset, whether system or information, and why, and ensures access is monitored and compliant with policy. Understand and address risks to the asset, and providing assurance to the SIRO. Ensure there is a legal basis for processing and for any disclosures, and Refer queries about any of the above to the Information Governance Senior Manager. 3.5 Information Governance Senior Manager 3.5.1 The Information Governance Senior Manager will: Maintain an awareness of information governance issues within the NHS England. Review and update the information governance policy in line with local and national requirements. Undertake the role of Information Security Officer, with support from the ICT Technical & Security Architect. Review and audit all procedures relating to this policy where appropriate on an ad-hoc basis, and Ensure that line managers are aware of the requirements of the policy. Status: Approved Next Review Date: March 2017 Page 10 of 19

3.6 Corporate ICT Senior Manager 3.6.1 The Corporate ICT Senior Manager is responsible for: The formulation and implementation of ICT related policies and the creation of supporting procedures, and ensuring these are embedded within the service developing, implementing and managing robust ICT security arrangements in line with best industry practice; Effective management and security of the NHS England ICT resources, for example, infrastructure and equipment; Developing and implementing a robust IT Disaster Recovery Plan; Ensuring that ICT security levels required by NHS Statement of Compliance are met; Ensuring the maintenance of all firewalls and secure access servers are in place at all times, and; Acting as the Information Asset Owner for the ICT infrastructure with specific accountability for computer and telephone equipment and services that are operated by corporate and clinical work force, e.g. personal computers, laptops, personal digital assistants and related computing devices, held as a NHS asset. 3.7 Line Managers 3.7.1 Line managers will take responsibility for ensuring that the Information Governance Policy is implemented within their group or directorate. 3.8 All staff 3.8.1 It is the responsibility of each employee to adhere to the policy. 3.8.2 Staff will receive instruction and direction regarding the policy from a number of sources: Policy/strategy and procedure manuals; Status: Approved Next Review Date: March 2017 Page 11 of 19

Line manager; Specific training course; Other communication methods, for example, team meetings; and Staff Intranet. 3.8.3 All staff are mandated to undertake the Introduction to Information Governance e-learning module within their 1 st year of employment. For staff that have already taken the mandatory Introduction to Information Governance module in previous years, will undertake one of the modules listed below:- The Information Security Guidelines Secure Handling of Confidential Information IG : The Refresher Module 3.8.4 Information governance training is required to be undertaken on an annual basis. 3.8.5 All staff must make sure that they use the organisation s IT systems appropriately, and adhere to the Acceptable use of ICT Policy. 4. Framework 4.1 NHS England has developed a framework for its Information Governance Policy. This is supported by a set of Information Governance policies and related procedures to cover all aspects of Information Governance which are aligned with the NHS Operating Framework and the Information Governance toolkit requirements. 4.2 The Key Information Governance Policies are: Policies Data Protection Policy This policy sets out the roles and responsibilities for compliance with the Data Protection Act. Freedom of Information Policy This policy sets out the roles and responsibilities for compliance with the Freedom of Information Act and Status: Approved Next Review Date: March 2017 Page 12 of 19

Environmental Information Regulations. Confidentiality Policy Information Security Policy Document & Records Management Policy This policy lays down the principles that must be observed by all who work within NHS England and have access to personal or confidential business information. All staff must be aware of their responsibilities for safeguarding confidentiality and preserving information security in order to comply with common law obligations of confidentiality and the NHS Confidentiality Code of Practice. This policy is to protect, to a consistently high standard, all information assets. The policy defines security measures applied through technology and encompasses the expected behaviour of those who manage information within the organisation This policy is to promote the effective management and use of information, recognising its value and importance as a resource for the delivery of corporate and service objectives. Information Sharing Policy The policy will ensure that all information held or processed by NHS England is made available subject to appropriate protection of confidentiality and in line with the terms and conditions under which the data has been shared with NHS England. This policy sets out what is required to ensure that fair and equal access to information can be provided and is supported by a range of procedures. 4.3 An Information Governance User Handbook provides a brief introduction to Information Governance and summaries the key user obligations that support NHS England Information Governance policies. The IG Handbook must be read and the declaration accepted by every member of staff within the policy scope. Status: Approved Next Review Date: March 2017 Page 13 of 19

5. Information Governance and Records Management Group 5.1. NHS England will establish an Information Governance and Records Management Group to monitor and co-ordinate implementation of the and the Information Governance Toolkit requirements and other information related legal obligations. 6. Information Governance Team 6.1. The Corporate Directorate Information Governance Team will provide expert advice and guidance to all staff on all elements of Information Governance. The team is responsible for: Providing advice and guidance on internal information governance to all staff. Working with the Patients and Information Directorate Information Governance team to ensure there is consistency of Information Governance across the organisation. Developing internal Information Governance policies and procedures. Working with the Patients and Information Directorate Information Governance team to establish protocols on how information is to be shared. Developing Information Governance awareness and training programmes for staff. Ensuring compliance with Data Protection, Information Security and other information related legislation. Providing support to the team who handle freedom of information requests. Implementing DH/NHS England system wide Information Governance guidance and policy, and Providing support to the Caldicott Guardian and Senior Information Risk Owner (SIRO) for internal Information Governance related issues. 6.2. The Patients and Information Directorate Information Governance team will be responsible for: Information Governance assurance for Care.data. Status: Approved Next Review Date: March 2017 Page 14 of 19

Implementation and monitoring of the Anonymisation Standard for publication for data published by NHS England. Leading on the scoping, commissioning, quality assuring and where appropriate providing, Information Governance advice and guidance to the NHS as a whole, including implementation of the Caldicott 2 Review recommendations. Leading on the scoping, commissioning, quality assuring of Information Governance Information Standards. Working with Transformation & Corporate Operations Directorate Information Governance team to ensure there is consistency of Information Governance across the organisation and to establish protocols on how information is to be shared. Working with external stakeholders to ensure consistency of information governance standards and requirements across the health and social care system. 7. Distribution and Implementation 7.1 Distribution Plan 7.1.1 This document will be made available to all Staff via the NHS England internet site. 7.1.2 A global notice will be sent to all Staff notifying them of the release of this document. 7.1.3 A link to this document will be provided from the Transformation & Corporate Operations Directorate intranet site. 7.2 Training Plan 7.2.1 A training needs analysis will be undertaken with Staff affected by this document. 7.2.2 Based on the findings of that analysis appropriate training will be provided to Staff as necessary. Status: Approved Next Review Date: March 2017 Page 15 of 19

7.2.3 Guidance will be provided on the Transformation & Corporate Operations Information Governance intranet site. 8. Monitoring 8.1 Compliance with the policies and procedures laid down in this document will be monitored via the Information Governance team, together with independent reviews by both Internal and External Audit on a periodic basis. 8.3 The Information Governance Senior Manager is responsible for the monitoring, revision and updating of this document on a 3 yearly basis or sooner if the need arises. 9 Equality Impact Assessment 9.1 This document forms part of NHS England s commitment to create a positive culture of respect for all staff and service users. The intention is to identify, remove or minimise discriminatory practice in relation to the protected characteristics (race, disability, gender, sexual orientation, age, religious or other belief, marriage and civil partnership, gender reassignment and pregnancy and maternity), as well as to promote positive practice and value the diversity of all individuals and communities. 9.2 As part of its development this document and its impact on equality has been analysed and no detriment identified. Status: Approved Next Review Date: March 2017 Page 16 of 19

10. Associated Documents 10.1 The following documents will provide additional information. REF NO DOC REFERENCE NUMBER TITLE VERSION Freedom of Information Policy 1.0 Data Protection Policy 2.0 Confidentiality Policy 2.0 Document and Records Management Policy 3.0 Information Security Policy 2.0 Information Sharing Policy 1.0 Information Governance User Handbook 1.0 Status: Approved Next Review Date: March 2017 Page 17 of 19

Version Control Tracker Version Number 1.1 April 2013 2.0 June 2014 Date Author Title Status Information Governance Senior Manager Information Governance Senior Manager Approved Comment/Reason for Issue/Approving Body Update the existing policy to reflect the changes in IG responsibilities. Updated to reflect change of Policy directorate to Transformation & Corporate Operations directorate Status: Approved Next Review Date: March 2017 Page 18 of 19

NHS England 2014 First published April 2013 Status: Approved Next Review Date: March 2017 Page 19 of 19