This leaflet provides information about why the NHS records information about you and how it is used; with whom we may share information; your right to see your health records; and how we keep your records confidential.
Why we collect 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
The way that health information is recorded has changed over time and it is now possible for health care professionals to add information into a central clinical system which links directly to your GP record. We also have electronic tools that enable the NHS to understand the risks your health is putting you at and to put in place services that will reduce this risk.
This provides you with a better level of care because the people caring for you have accurate and up-to-date information about your health.
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
In order for the NHS to make the best use of its resources we need to understand what care we are providing and to whom. Whenever we do not need to know it is about you individually we will only use your information in an anonymised form. Your information can help the NHS to:
- Plan services to ensure we meet the needs of our population in the future. This includes predictive and preventative care in a proactive care setting
- look after the health of the general public, e.g. notifying central NHS groups of outbreaks of infectious diseases
- report events to the appropriate authorities when we are required to do so by law, e.g. notification of births
- undertake clinical audit of the quality of services provided
- report and investigate complaints, claims and untoward incidents
- prepare statistics on our performance for the Department of Health
- review our care to make sure that it is of the highest standard
- teach and train health care professionals
- conduct health research and development
- pay your GP or hospital for the care you have received
- audit NHS accounts
There may be other uses to which Health Care Records may be of assistance to the NHS.
How we keep 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, and in certain circumstances, social care.
The CCG 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.
You have the right
You have the right to confidentiality under the Data Protection Act 1998, 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.
- We are 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
- Everyone working in the NHS or for Social Services has a legal duty to keep information about you
- Records will be kept in line with the Department of Health Records Management Code of Practice
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 only share information if
- it ensures you receive the best care possible
- 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 (1998) 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.