Your Medical Information
Your Medical Record
When you visit an NHS or social care service, information about you and the care you receive is recorded and stored in a health and care record.
This is so people caring for you can make the best decisions about your care.
For more information about your medical record, please see the following: https://www.nhs.uk/using-the-nhs/about-the-nhs/your-health-records/
Cheshire Care Record
The Cheshire Care Record (CCR) is an overview of your health and social care information in one digital record.
Whether you are visiting your GP, attending hospital, or being seen in your own home by a community nurse or social worker, we want you to get the best care but we can only do this if all the health and social care professionals involved in your care have access to the information they need.
Your shared health and social care information will include test results, medications, allergies and social or mental health information.
The CCR provides the following important benefits:
- Better health care – by improving all aspects of patient care, including safety, effectiveness, putting the patient at the very centre of the picture, better communication, timeliness, efficiency and equity.
- Improved efficiencies and lower health care costs by promoting preventative medicine and improved coordination of health care services, as well as by reducing waste and unnecessary or repeated tests.
- Better clinical decision making by securely integrating patient information from multiple sources.
For more information on the Cheshire Care Record, including what information is held, who can access your record, and additional benefits, please see: https://www.cheshirecarerecord.co.uk/
Opting Out from having a Cheshire Care Record
If you would like to opt-out from having a Cheshire Care Record, please complete the following form and return it to reception. Please see below if you'd like to return it via email: Cheshire Care Record Consent Form
Summary Care Record
The Summary Care Record (SCR) is an electronic record that contains a short summary of important patient health information created from General Practice (GP) medical records. This includes basic information about allergies, medication and any reactions that the patient has had to medication in the past. It can be seen and used by authorised staff in the health and care system involved in the patient's direct care.
During the coronavirus outbreak, extra information has been added to your Summary Care Record. This includes significant medical history (past and present), reasons for medicines, care plan information, and vaccinations.
The change to include Additional Information in a patient’s SCR will enable health and care professionals to have better medical information about the patient they are treating at the point of care and has been directed via the Control of Patient Information (COPI) Covid-19 – Notice under Regulation 3(4) of the Health Service Control of Patient Information Regulations 2002.. This change will apply for the duration of the coronavirus (COVID-19) pandemic only. Unless alternative arrangements have been put in place before the end of the emergency period, this change will be reversed.
Patients can be reassured that if they have previously opted-out of having a Summary Care Record or declined to provide consent to share their Additional Information, their preference will continue to be respected and applied.
For more information about the Additional Information within the Summary Care Record, please see the following: https://digital.nhs.uk/services/summary-care-records-scr/additional-information-in-scr
The Benefits of using Additional Information in SCR
By including Additional Information in a patient's SCR, more information is available to health and care staff viewing the SCR. It will then be automatically updated when the GP record is updated. This is a quick and effective way to:
- Improve the flow of information across the health and care system
- Increase safety and efficiency
- Improve care
- SCR Additional Information is particularly useful for people with complex or long term conditions, or patients reaching end of life.
By including this Additional Information in your SCR, health and care staff can give you better care if you need health care away from your usual GP practice:
- In an emergency
- When you're on holiday
- When your surgery is closed
- At out-patient clinics
- When you visit a pharmacy
For more information, please see: https://digital.nhs.uk/services/summary-care-records-scr/summary-care-records-scr-information-for-patients
Opting Out of the Summary Care Record
You can ask to “opt out” of the SCR if you wish by asking the practice to amend your records.
However, you need to think carefully before opting out here. The SCR allows doctors throughout the country to access your basic information if they need, which will help them look after you, particularly if you are brought in unconscious. Many GP Practices recommend to their patients that they should not block the SCR data extraction from taking place.
- Do Nothing: Your Summary Care Record will remain in place and accessible for your care
- Express Consent – Core SCR Only: You wish to share information about medication, allergies and adverse reactions only.
- Express Consent – Core & Additional SCR: You wish to share information about medication, allergies and adverse reactions and further medical information that includes: Your significant illnesses and health problems, operations and vaccinations you have had in the past, how you would like to be treated (such as where you would prefer to receive care), what support you might need and who should be contacted for more information about you.
- Express Dissent (Opt-out): You DO NOT want any information shared with other healthcare professionals involved in your care.
If you would like to update your consent for your Summary Care Record, please complete the following form and return it to reception. Please see below if you'd like to return it via email: Summary Care Record Consent Form
General Practice Data for Planning and Research (GPDPR)
This practice is supporting vital health and care planning and research by sharing your data with NHS Digital. For more information about this see the GP Practice Privacy Notice for General Practice Data for Planning and Research (GPDPR).
NHS Digital collect and store some information from everyone's health and care records because of their role in health and care. They have two main responsibilities. They:
- Run and manage computer systems that link different parts of health and care together and improve individual care
- Collect some specific health and care data to check how the health and care service is doing and to improve everyone's care
To carry out these duties, they need to collect, store, use and sometimes share information about you.
For more information about who may access this data, please see the following links:
Opting Out of National Data Sharing
If you don’t want your identifiable patient data to be shared for purposes except for your own care, you can opt-out by registering a Type 1 Opt-out or a National Data Opt-out, or both. Your individual care will not be affected if you opt out using either option.
- A Type 1 Opt-out prevents confidential patient information being shared outside a GP practice for purposes other than direct care.
- A National Data Opt-out prevents confidential patient information being shared outside NHS Digital for purposes beyond the individual's direct care.
Type 1 Opt-out (opting out of NHS Digital collecting your data)
If you do not want your identifiable patient data to be shared outside of the GP practice for purposes except your own care, you can register an opt-out with us. This is known as a Type 1 Opt-out.
You can change your mind at any time and withdraw a Type 1 Opt-out.
To register a Type 1 Opt-out, please complete the following form and return it to reception. Please see below if you'd like to return it via email: Type 1 Opt-Out Form
National Data Opt-out (opting out of NHS Digital sharing your data) – Previously known as a Type 2 Opt-out
Previously you could tell your GP practice if you did not want NHS Digital to share confidential patient information that they collect from across the health and care service for purposes other than your individual care. This was called a Type 2 Opt-out.
The Type 2 Opt-out was replaced by the National Data Opt-out. Type 2 Opt-outs recorded on or before 11 October 2018 have been automatically converted to National Data Opt-outs.
The National Data Opt-out is a service that allows patients to opt out of their confidential patient information being used for research and planning.
If you do not want NHS Digital to share your identifiable patient data with anyone else for purposes beyond your own care, then you can register a National Data Opt-out:
- Via the 'Your Health' section of the NHS App
- Calling 0300 3035678
- Via https://www.nhs.uk/your-nhs-data-matters
For further information, please refer to the following links:
Returning Forms to the Practice via Email
Should you wish to return any opt-out forms to the practice via email, please use the following email address: firstname.lastname@example.org.
Please Note: We will only accept opt-out forms without a signature if they are received from the email address on your medical record.
Access To Medical Records
You have the right to access your health records. If you wish to view your own medical records please start by asking at reception. The usual procedure will involve signed consent from yourself, and an appointment with your doctor to go through your records so they can explain any medical terminology that you might not understand.
If you wish to have copies of your medical records then please inform reception. There is no charge but any additional requests may include administrative charges.
Personal Health Information
We ask you for information so that you can receive proper care and treatment. The practice keeps this information, together with details of your care, because it might be needed if you are seen again.
The practice may use some of this information for other reasons as detailed below:
- To help us protect the health of the public generally;
- To see that the NHS runs efficiently;
- To plan for the future;
- To train staff and account for their actions;
- To assist with medical research.
Sometimes the law requires us to pass on registration information to assist other people involved in patient care. The NHS Central Register for England and Wales contains basic personal details of all patients registered with a general practitioner. The register does not contain clinical information. Everyone working for the NHS has a legal duty to keep information about patients confidential.
Patients may be receiving care from other people as well as the NHS. The staff in the practice work together with other areas of the NHS to improve patient benefits and the resources needed within primary care and by hospitals. We only ever pass on information about you if there is a genuine need for it, and if it is in yours and everyone’s interest. Whenever we can we will remove details which identify you.
The sharing of types of sensitive personal information is strictly controlled by law. Anyone who receives information from us is also under a legal duty to keep it confidential. Any disclosure of your medical records to a third party will only be done after signed consent to a specific instruction by yourself.
Data Protection: Your Personal Data is Safe
We are aware that recent events highlighted in the media concerning sharing your personal data (GPDPR) may have left you confused and worried.
This has led to a rise in the number of queries asking us who we actually share your personal data with, do we have the rights to and can we trust these external organisations to look after your personal data.
We would like to assure you that as a practice we take your personal data very seriously and we have certain processes in place to make sure your personal data is in safe hands at all times.
As a practice we must adhere to UK Data Protection laws, the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act 2018. Both pieces of legislation are around to make sure we look after your data. Where we do not follow any part of the Data Protection laws we are at risk of being investigated by the Information Commissioner’s Officer (ICO) on your behalf, and possibly being issued with a fine or warning. The ICO is an independent advisory body who report directly to Parliament and make sure your rights around your personal data are protected.
To help us keep on track and make sure we abide by these laws we complete something called the Data Security and Protection Toolkit (DSPT) that incorporates the laws. We are required to complete this annually. It helps us measure how we are doing and keeps us in line with the law.
There will be times when we have to share your personal data with external organisations / companies in order to provide you with the care you need. However, we only do this where we need to, where we have a legal reason to do so and when we are happy they will continue to safeguard your personal data. An example would be the Clinical IT system we use that holds your medical records. This is supplied by an IT company who will host your personal data to enable us to use the system.
In any event where we share your personal data we will conduct the necessary Data Protection checks with the external organisation. Like us, they are required by data protection law to provide us with relevant assurances that any personal data we share with them will remain secure. Under the UK GDPR they are required to provide us with documents to assure us and this will include contracts which must include UK GDPR clauses. If an organisation does not process your personal data in line with law they too will be investigated by the ICO.
We cannot share your personal data without a legal basis, which means we cannot give your personal data to anyone ‘just because’ they want it. The UK GDPR sets out 6 legal bases we can use, the most common one you would have heard of is ‘consent.’ Consent is not often used in healthcare and where we are using your personal data for direct care, it just would not work and the UK GDPR recognise this so we apply a legal basis called ‘public tasks.’ Public tasks covers the use of personal data where it relates to either being in the interest of the patients care or the public interest. This means that we do not need to ask for your consent, although we are obliged to be open and transparent with your personal data which we do via our Privacy Notice.
We certainly will not sell your personal data to anyone.
When we share your personal data we need to abide by the UK GDPR principles, one of which is called ‘data minimisation’ – this means we can legally only share what is relevant and necessary for the task.
Finally, along with completing the DSPT (as mentioned above) where we have any data protection concerns or need advice we have a dedicated Information Governance team who are on hand to guide us through the do’s and don’ts.
I hope this information has provided you with assurance that we take the necessary steps to make sure your personal data is safe when in our care and that where we share your personal data we do so only if the law allows us to.
For more information about your personal data and how it is processed, please see the following page: