In the NHS we always aim to provide you with the highest possible quality health care. As part of this it is important that we keep comprehensive up to date records about you, which can either be kept in writing or stored on our computer systems.
The kind of information that we keep in our records may include:
- Basic details about you, such as address, date of birth, next of kin
- When we have seen or had contact with you
- Notes and reports about treatment you have received and care you need
- Results e.g. x-rays, blood tests and screening including evaluations of your health risk
- Relevant information from people who care for you and know you well, such as health professionals and relatives
This information allows medical professionals to see the full picture of your individual health care needs and make sure you receive the right treatment, first time.
How your records are used to help you
With your consent, relevant parts of your named health record can be shared to help other professionals to provide the right care for you. For example, if you have to visit an accident and emergency department, if the doctor is able to view your health records, they can be sure that they understand enough about your medical history, current medication and treatment to treat you safely and effectively. You will be asked for your consent before anyone is able to view these records, unless you are unable to make such a choice through incapacity or severe injury.
Other partner organisations we might share your date with include
- Local healthcare and ambulance providers
- Your Local Authority, Social Services and Education organisations
- Your voluntary or private sector care provider
- Commissioners of your health services
This will be on the basis of having your prior consent to share information that identifies you, or your personal identity being removed from the record before it is shared.
We may also use information in your records, in a non-identifiable form, to help us plan for the future healthcare needs of you and others. This might include identifying risks to help prevent illness in the first place, planning for extra services in your area and helping people to plan, buy and keep track of health services. Records used in this way will always be done so anonymously with no identifiable links to you.
Any sharing of your named record will be in line with the NHS Code of Practice for Confidentiality, which you can find out more about below.
We will not share your information with other third parties, such as insurance companies, without your explicit consent.
How we keep your records confidential
Everyone working for the NHS has a legal and contractual duty to keep information about you confidential in line with the NHS Confidentiality Code of Practice. We also have information security and data protection policies to safeguard your information.
We have a duty to
- Maintain full and accurate records of the care we provide to you
- Keep records about you confidential, secure and accurate (including after you die)
You also have the right to confidentiality under the Data Protection Act 1998, the Human Rights Act 1998 and the common law duty of confidence.
The NHS Care Record Guarantee sets out the standards on how patient confidential information is used in the NHS and what control you can have over this.
It includes information on:
- Your access to your own records their content and security
- How NHS Staff access will be monitored and what controls are in place to prevent unauthorised access
- Options you have to limit further access by NHS or contracted Staff
- What happens if you are unable to make decisions for yourself
More information on the Care Record Guarantee can be seen online here.
We only use secure methods to transfer your information between NHS computer system and all processes meet NHS security requirements.
Apart from your GP and other medical staff or healthcare professionals (e.g. physiotherapists) involved in your care, only a number of approved GP Practice staff and a very small number of approved analysts will be able to see data that identifies you and only then under strict security restrictions.
We check that anyone who wants to see your records has the correct authority to do so. Access to your records is recorded and auditable, so we will always be able to check who has seen them.
When we might use or share your named health record without asking you
There are very few occasions when we will share your named health record without your permission. This is when permission is given by the Secretary of State on advice from the Health Research Advisory Group for example for medical research, keeping registers of cancer patients or checking quality of care.
A senior health professional may also permit disclosure where the public interest outweighs your right to confidentiality. This is very rare but could include when:
- A serious crime has been committed
- There are serious risks to the public or staff
- It is necessary to protect children or vulnerable adults who are not able to decide for themselves whether their information should be shared.
Access to your Health Records
If you want to see or obtain a printed copy of your records speak to the healthcare professional treating you or contact the Practice Manager at your local surgery.
Please note you may have to pay to get a copy of the records, and if you are asking for someone else’s records you will need to provide evidence that you are authorised to do so on their behalf.
If you think anything is inaccurate or incorrect in your health records, please inform the organisation holding your information.
If you have concerns about what information is held or shared about you please discuss this with your GP or a member of practice staff. If, after discussion, you wish to restrict or prevent use of your information outside of the Practice please tell them and we will make the necessary arrangements. There are various options available to you which practice staff will explain.