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Patient Record Sharing

Record Sharing

What do we mean by record sharing?
Your medical information is held on an electronic record and each time you see a doctor or nurse at the practice information is added. From time to time it may be necessary for you to see clinical staff in other NHS settings for example District nurses, physiotherapists, hospital specialists or even in an emergency, doctors in A&E.

It is possible for staff in these other organisations to access some or all of your clinical record in order for them to understand your medical conditions, medications and any allergies and therefore look after you safely. This is referred to as record sharing.

It is important to understand that this is about clinical care and sharing with other NHS organisations. This is not about sharing for other purposes whether it be for research, data collection or any other purposes.

Consenting/dissenting to share:
Patients have the choice as to whether or not other NHS organisations can see their record. This is known as consent to share. Given the improved safety and quality of care from having access to the medical records, NHS Sheffield Clinical commissioning groups policy, like many other parts of the country, is to set clinical systems to “assume consent”. Carterknowle and Dore Medical Practice conforms to this policy and so all our patient records are set to be shared with other NHS organisations/departments unless otherwise stated by the patient.

Those patients wishing for their records not to be shared can opt out.  In those patients who have chosen to opt out the practice has taken the step of ensuring this cannot be overridden.

This means that even in an emergency other clinicians would not be able to access your record.

It is important to note the “unless otherwise stated by the patient” part of the statement above, a patient who has completed the relevant forms to opt out of record sharing in the past WILL NOT have their record shared from our system.

New patients registering with our practice need to complete the relevant sharing consent forms before we can process their registration.  

What information is shared?
There are two forms of information in that can be shared.  These are the Summary Care Record, and the full Patient Record.

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Summary Care Records (SCR)

The SCR is an electronic record of only important patient information, created from GP medical records.

The SCR holds important information about:

  • current medication
  • allergies and details of any previous bad reactions to medicines
  • the name, address, date of birth and NHS number of the patient

The SCR is created automatically through our clinical system and is updated each time the record is accessed within the practice.

Access to SCR information is available across the whole NHS, and means that care in other settings is safer, reducing the risk of prescribing errors. It also helps avoid delays to emergency and urgent care.

Opt out
To opt out of having an SCR please print out and complete the form below and bring into the practice.  Alternatively you can request an opt out form from reception to complete in the building.

SCR Opt Out Form

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Record_Sharing_IconMain Record Sharing

Electronic records are kept in all the places where you receive healthcare. These places can usually only share information from your records by letter, email, fax or phone. At times this can slow down your treatment and mean information is hard to access. In addition letters and faxes could be lost and are not as safe as sharing information through a secure electronic system. The practice uses a clinical computer system called SystmOne to record patient information securely. This information can then be shared with other clinicians and healthcare services so that everyone caring for you is informed about your medical history.

This record is known as your health, medical or care record

Your care record may include:

  • Basic details about you such as name, address and next of kin
  • Details of any diagnosis and treatment you receive including drug prescriptions
  • Results of investigations such as blood tests and X-rays
  • Details of contact you have with other health or social care professionals such as visits to clinics
  • Relevant information from other professionals and those who care for you

Record Sharing
In order to deliver the best integrated health and social care services to you in Sheffield we share relevant personal data between professionals involved in your care - this means sharing records between your GP, primary care, hospitals, out-of-hours, ambulance services (111 and 999) and other health and social care organisations including the Local Authority.
Sharing your records helps us to ensure you receive the safest, most appropriate care for you, and reduces the need for you to repeatedly tell your story.

How Sharing Works
Each NHS organisation that has involvement with your care has their own sharing setting.  This can either be “record shared” or “record not shared”.  The result of this setting determines what can be seen by different departments.

A good analogy is to think of your records as a large pot, containing all your medical information.  When an organisation enables sharing they can add to the contents of the pot, as well as see what’s in the pot already.  When an organisation disables sharing (record not shared) then the only information they can see is the data they hold locally, also any new information they add to their records will not be shared out to the other organisations.  


Full Sharing

All NHS departments can access the full record, and see all the information created by other departments

Sharing_Restricted

Restricted Sharing

In this example the GP practice and Physiotherapy have dissented from record sharing.  This results in Sheffield Hospitals and Out of Hours being able to see what each other department are contributing to the record, but NOT anything the GP surgery, or Physiotherapy are adding into the record.  Also, both the GPs and Physio cannot see any other data on the record, other then what they themselves have placed into the pot.

Security & Confidentiality
NHS and social care staff will ensure that all personal data is handled in a lawful manner.
Information about you is securely managed and controlled within Sheffield NHS and social care systems. We won’t share your records with anyone who isn’t involved in your treatment, care or support. Professionals are obliged through law to protect your information and only use that which is relevant to the care they are giving. They are bound by rules set out in law, by their employer and by their professional bodies for example the GMC for doctors or NMC for nurses.

Your Rights
You have the right to access your records - for more information please contact the practice or ask in reception for more details.

You have the right to opt out of your records being shared at any time. However, by not agreeing to share your records you may not always receive the best available service that meets your specific needs.

Opt Out
To opt out of record sharing within Carterknowle & Dore Surgery please print out and complete the form below and bring into the practice.  Alternatively you can request an opt out form from reception to complete in the building.

Record Sharing Consent Form

Please note that if you decide to opt out of record sharing from the practice it is only the data we ourselves have regarding your medical record that will be unavailable to other NHS organisations.  To fully opt out of record sharing you will need to contact all other departments that have sharing enabled and request to complete their opt out forms.  

To help facilitate this we can provide a list of organisations that currently have record sharing access to your records.  Please ask in reception for more details.

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Further Reading

Our clinical system provider (TPP) has produced further information regarding sharing.  Please find the links below to their pdf documents:

Information-on-sharing-for-patients-implicit-consent

Information-on-sharing-for-patients-Explicit-consent

Sharing_Patient-FAQs

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Past information and advice



Your Sheffield Health and Care Records 

This guide explains how and why we share patient information across Sheffield health and care services. It summarises changes in the health and care system, our future plans, patients’ rights, choices, how to opt out of record sharing, and where to get more information.

This guide expands upon the “Your Sheffield Health and Care Records” poster displayed in your GP practice. The highlighted sections are from the poster.

Information used to support your care

When you see a doctor, nurse or any other health or social care professional, we ask you to share information about yourself. This helps us offer treatment and care adapted to your needs. We keep a record of relevant information, which may be written down or held on computer. This record is known as your health, medical or care record.

Your care record may include:

  • Basic details about you such as name, address and next of kin
  • Details of any diagnosis and treatment you receive including drug prescriptions
  • Results of investigations such as blood tests and X-rays
  • Details of contact you have with other health or social care professionals such as visits to clinics
  • Relevant information from other professionals and those who care for you

Different health and care professionals involved in your care may make their own notes, so you may have care records in different parts of the NHS and social care services.

We share information about you when it is necessary for your direct care within your care team, unless you have registered an objection.

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Changes starting December 2015

Your GP practice will recognise the following as the list of selected information from your GP primary care record that is starting to be shared with other care providers (as shown in the Record Sharing section below):

  • Patient Details (NHS number, Name, Address, Date of Birth, Gender)
  • Conditions / Problems / Diagnoses – Current and Past
  • Medication – Current and Past
  • Risks and Warnings (eg Allergies / sensitivities, Contraindications to medication, or conditions that affect prescribing practice)
  • Procedures (Operations, Vaccinations)
  • Investigations (eg ECG, Blood Tests, Radiology)
  • Examinations (Blood Pressure results only)
  • Contacts, Admissions, Referrals, Consultations
  • Specific Exclusions – details about the following are not shared – termination of pregnancy, sexually transmitted infections, HIV, infertility related concerns, gender identity concerns.

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Summary Care Record

The Summary Care Record has been in existence for some years and provides important medical information to clinicians in emergency, urgent or unplanned care to support patient safety and quality of care. It is created from your GP record and consists of essential information about medication, allergies and adverse reactions. You do have the choice to opt out of this.

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Summary Care Record with additional information

There is a new extended version of the Summary Care Record that looks to increase the level of detail that is shared, this has been released recently (in Autumn 2015) and is currently available with the patients explicit consent). There will be more information available from the NHS about this in the future.

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What are we aiming to achieve?

  • Our aim is to share relevant patient/citizen information appropriately (and securely) across the Sheffield health and care system between professionals (with patient consent at the point of viewing) in order to:
  • Improve patient care & safety - through better informed clinical decisions enabling more appropriate care (eg avoiding drug contra-indications), and supporting safeguarding
  • Improve the patient experience – through patients not having to repeatedly repeat their details, and not having to unnecessarily repeat clinical tests
  • Improve effectiveness & efficiency of the delivery of care - though improved administration systems (eg reduced waiting times)
  • In future we also want to give patients access (and ownership) of their own records.

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Record Sharing

In order to deliver the best integrated health and social care services to you in Sheffield we share relevant personal data between professionals involved in your care - this means sharing records between your GP, primary care, hospitals, out-of-hours, ambulance services (111 and 999) and other health and social care organisations including the Local Authority.

Sharing your records helps us to ensure you receive the safest, most appropriate care for you, and reduces the need for you to repeatedly tell your story.

Staff at other organisations, referred to above, may view a subset of your GP primary care record – you should usually be asked for your consent to view the record at the time you are seen (this may be at a clinic attendance, or during a telephone consultation, for example if you have phoned 111 or the GP out of hours service).

You can ask for specific notes in your record to not-be-shared, whilst allowing the rest of the record to be shared – ask your practice to log your preference on your records.

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Security & Confidentiality

NHS and social care staff will ensure that all personal data is handled in a lawful manner.

Information about you is securely managed and controlled within Sheffield NHS and social care systems. We won’t usually share your records with anyone who isn’t involved in your treatment, care or support.

An exception would be when protecting vulnerable children or adults, or where you have given your consent for your identifiable information to be shared for a given purpose (for example in the event of a complaint).

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Legal Position

We must use patient data within the legal framework established by:

  • The common law duty of confidence
  • The Data Protection Act 1998
  • The Human Rights Act 1998
  • The Health and Social Care (Safety and Quality) Act 2015

The law changed in October 2015. The ‘Health and Social Care (Safety and Quality) Act 2015’ came into being and gives us a new duty to share. In essence the new law says (paraphrased):

 

[We] must ensure that the information is disclosed to… any other relevant health or adult social care commissioner or provider with whom the relevant person communicates about the individual… [where] the disclosure is likely to facilitate the provision to the individual of health services or adult social care… [and is] in the individual’s best interests… [unless] the individual objects, or would be likely to object

 

There are occasions under law where we are required to share some aspects of your records. For example when there is an outbreak of a serious communicable disease like Ebola, or during the investigation of a serious crime.

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Data Processing

There are two different GP practice systems currently in use in Sheffield. These two systems are used widely within England and are provided by commercial companies who operate to strict security and confidentiality rules – your data is held and processed securely as if it was managed within the NHS.

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Citywide Governance

 

  • Sheffield has established shared governance arrangements with representation from the Clinical Commissioning Group, Sheffield NHS providers (Primary Care Sheffield, Sheffield Teaching Hospital, Sheffield Childrens Hospital, and the Health and Social Care Trust), Local Authority, Yorkshire Ambulance Service and the Local Medical Committee.
  • The group is developing a citywide Sheffield health and social care ‘Record Sharing Framework’ to ensure we have clear, shared rules that we all work to.

Your Rights

You have the right to access your records - for more information please ask your care provider.
You have the right to opt out of your records being shared at any time. However, by not agreeing to share your records you may not always receive the best available service that meets your specific needs.

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NHS constitution

The NHS Constitution sets out the following patient’s legal rights and pledges:

  • You have the right of access to your own health records and to have any factual inaccuracies corrected.
  • You have the right to be informed about how your information is used.
  • You have the right to request that your confidential information is not used beyond your own care and treatment and to have your objections considered, and where your wishes cannot be followed, to be told the reasons including the legal basis.
  • The NHS also commits to anonymise the information collected during the course of your treatment and use it to support research and improve care for others.
  • Where identifiable information has to be used, to give you the chance to object wherever possible.

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How to Opt Out

We recommend that your records are shared, however, you can ask for part of your record to not-be-shared, or you can ask for the whole record to not-be-shared. Ask your practice to log your preference on your records – either ask your GP or at reception.

Please be aware that by not agreeing to share your records you may not always receive the best available service that meets your specific needs. For example the GP out of hour’s service may not be fully aware of which medications you are currently taking and so be unable to advise on the best course of action for you.

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Data Protection Act

Organisations that handle personal information have a legal obligation to protect that information under the Data Protection Act 1998.  The Act gives you the general right to apply to see, or to be given, a copy of the personal information held about you.  Maximum fees for access and providing copies are set down by law.

You have the right to request access to your records, or ask who has accessed it. Please contact your practice directly if you wish to request access.

If you think that your practice has not complied with the Act you may find it helpful to talk to the practice manager about this. If you wish to complain you can either complain directly to the practice, or to NHS England. If you are not satisfied with the response to your complaint you can contact the Parliamentary and Health Service Ombudsman.

Alternatively you can raise your concerns with the Information Commissioners Office. You have the right to complain to, appeal to, or raise your concerns with the Information Commissioners Office and ask them to investigate whether the practice has complied with the Data Protection Act 1998.

NHS England: https://www.england.nhs.uk/contact-us/complaint/ 0300 311 2233

Parliamentary and Health Service Ombudsman: http://www.ombudsman.org.uk/

0345 015 4033

Information Commissioner’s Officer:  www.ico.gov.uk


Information Commissioner’s Office,
Wycliffe House,
Water Lane,
Wilmslow,
Cheshire,

SK9 5AF

You can call the ICO helpline on 0303 123 1113 (local rate) or 01625 545 745 if you prefer to use a national rate number.

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For Further Information

Please discuss with your GP, reception, or see the Sheffield CCG website:

http://www.sheffieldccg.nhs.uk/about-us/looking-after-your-information.htm

Links to relevant national information are shown below:The NHS Constitution https://www.gov.uk/government/publications/the-nhs-constitution-for-england.

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