Your Health Records

Health records play a vital role in the NHS from storing important clinical information that is essential to your care to being used to improve public health and services.

Your Information And How The NHS Uses It

Do you know:

• Why the NHS collects information about you and how it is used?
• With whom we may share information?
• Your right to see your health records?
• How we keep your records confidential?

Why The NHS Collects Information About You

In the NHS we aim to provide you with the highest quality health care.

To do this we must keep records about you, your health and the care we have provided or plan to provide to you.

Your doctor and other health professionals caring for you, such as nurses or physiotherapists, keep records about your health and treatment so that they are able to provide you with the best possible care. These records are called your ‘health care record’ and may be stored in paper form or on central computer databases and may include:

• Basic details about you, such as your address, date of birth, and next of kin
• Contact we have had with you, such as clinical visits
• Notes and reports about your health
• Details and records about your treatment and care
• Results of x-rays, laboratory tests etc.

How Your Records Are Used To Help You

Your health care record is used to ensure that:

• Health care professionals looking after you have accurate and up-to-date information about you to help them decide on any future care you may require
• Full information is available should you see another doctor or be referred to a specialist or another part of the NHS
• There is a good basis for assessing the type and quality of care you have received your concerns can be properly investigated if you need to complain.

How your records are used to help the NHS

• Looking after the health of the general public, e.g. notifying central NHS groups of outbreaks of infectious diseases.
• Reporting events to the appropriate authorities when we are required to do so by law, e.g. notification of births.
• Paying your GP or hospital for the care you have received.
• The audit of NHS accounts and clinical audit of the quality of services provided Reporting and investigating complaints, claims and untoward incidents.
• Planning services to ensure we meet the needs of our population in the future.
• Preparing statistics on our performance for the Department of Health.
• Reviewing our care to make sure that it is of the highest standard.
• Teaching and training health care professionals.
• Conducting health research and development.

There may be other uses to which health care records may be of assistance to you and to the NHS.

Anticipating And Planning Your Care In Advance (Risk Stratification)

This is a process that helps your GP to help you manage your health.

By using selected information from your health records, a secure NHS computer system will look at recent treatments you have had in hospital or in the surgery and at your existing health conditions. This will alert your doctor to the likelihood of a possible deterioration in your health. The clinical team at the surgery will use the information to help you get early care and treatment where it is needed.

The information will only be seen by qualified health workers involved in your care. NHS security systems will protect your health information and patient confidentiality at all times.

You have the right to opt out of your information being used for risk stratification profiling. GP practices should provide you with information explaining how your data will be used and what to do should you have any concerns or objections.

Financial Validation

The CCG has contracted NHS South CSU to use limited information about individual patients to validate financial invoices received for your healthcare. This service ensures that the invoice is accurate and genuine and supports our CCG in ensuring public monies are spent appropriately.

This service is performed in a secure environment and will be carried out by a limited number of authorised NHS South CSU staff. These activities and all identifiable information will remain within a Controlled Environment for Finance (CEfF) approved by NHS England.

How The NHS Keeps Your Information Safe

Everyone working for the NHS has a duty to keep your information confidential and secure.

However, from time to time, there may be a need to share some or all of your information with other health care professionals or NHS organisations so that we can work together to provide the best possible care.

We will only ever share your information if it is in the best interests for your NHS care.

We will not disclose any information that identifies you to anyone outside your care team without your express permission unless in exceptional circumstances, such as where we are required to do so by law.

The NHS Care Record Guarantee

This sets out the rules that govern how patient information is used in the NHS and what control you can have over this. It covers:

• People’s access to their own records.
• Controls on others’ access.
• How access will be monitored and policed.
• Options people have to further limit access.
• Access in an emergency.
• And what happens when someone cannot make decisions for themselves.

Everyone who works for the NHS or for organisations delivering services under contract to the NHS has to comply with this guarantee which was first published in 2005 and is regularly reviewed by the National Information Governance Board to ensure it remains clear and continues to reflect the law and best practice. It was last reviewed in January 2011. Please read the NHS Care Record Guarantee version 5 (2011) for more information.

You Have The Right

You have the right to tell us that you don’t want your information shared. You will need to tell us who you don’t want to share your information with and we won’t share your information, unless we have reason to believe you are at risk or if we have another legal requirement to share your information.

If you have any concerns about how your information may be shared, please discuss them with your health care provider, e.g. GP, nurse, dentist.

You have the right to confidentiality under the Data Protection Act 2018, the Human Rights Act 1998 and the common law duty of confidence. The Disability Discrimination and the Race Relations Acts may also apply. You also have the right to ask for a copy of all records about you:

• Your request must be made in writing (email is acceptable) to the organisation holding your information.
• There may be a charge to have a printed copy of the information held about you.
• The organisation is required to respond to you within 40 days. You will need to give adequate information (e.g. full name, address, date of birth, NHS number) and you will be required to provide identification before any information is released to you.

If you think that there are inaccuracies in your record, you have the right to request that these be corrected or annotated.

If you have any concerns about how your information may be shared, please discuss them with your health care provider, e.g. GP, nurse, dentist.

How The NHS Keeps Your Records Confidential

Everyone working for the NHS has a legal duty to keep information about you confidential.

Your information is legally protected by the Data Protection Act and the Caldicott Principles. Records will be kept in line with the Department of Health Records Management Code of Practice which determines the minimum length of time that records should be kept for.

Our guiding principle is that we hold your records in strict confidence.

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
• Provide information in a format that is accessible to you (for example, in large type if you are partially sighted).

We will not share information that identifies you for any reason unless:

• You ask us to do so
• We ask and you give us specific permission
• We have to do this by law
• We have special permission for health or research purposes
• We have special permission because the interests of the public are thought to be of greater importance than your confidentiality.

How You Can Arrange To See Your Own Health Records

The Data Protection Act 2018 entitles you to view the information contained in your health care record. Please contact the following organisations to see or obtain a copy of your records:

• For your main health care records, please contact your GP practice directly.
• In some cases, if you have received hospital treatment this may not be included in the health care records that your GP practice holds, so please contact the hospital directly.

You will need to apply in writing and then either your GP practice or hospital trust will contact you to advise you of the process.