Everyone working for the NHS has a legal duty to keep information about you confidential (private). All staff (clinical and Non-Clinical) within our organisation should not disclose information about your health, without your permission.
This means you can tell others about your visit, but we won’t.
Sometimes we may need to share information to make sure you receive the best possible care. You may be receiving care from other health professionals. So that we can all work together for your benefit we may need to share some information about you. We will always endeavour to consult you first.
We only ever use or pass on information about you if people have a genuine need for it in your and everyone’s interests. Whenever we can we shall remove details which identify you so you remain anonymous. The sharing of some types of very sensitive personal information is strictly controlled by law. Anyone who receives information from us is also under a legal duty to keep it confidential.
The main reasons for which your information may be needed are:
- giving you health care and treatment
- looking after the health of the general public
- managing and planning the NHS. For example:
– making sure that our services can meet patient needs in the future
– paying your doctor, nurse, dentist, or other staff, and the hospital which treats you for the care they provide
– auditing accounts
– preparing statistics on NHS performance and activity (where steps will be taken to ensure you cannot be identified)
– investigating complaints or legal claims
– helping staff to review the care they provide to make sure it is of the highest standard - training and educating staff (note that you can choose whether or not to be involved personally) · research approved by the Local Research Ethics Committee. (note that if anything to do with the research would involve you personally, you will be contacted to see if you are willing )
- if you agree, your relatives, friends and carers will be kept up to date with the progress of your treatment.
All our staff (including reception staff) are trained in issues surrounding confidentiality. If at any time you would like to know more about how we use your information contact your practice and we’ll be happy to answer your questions.
Your right to privacy
You have a right to keep your personal health information confidential (private) between you and your doctor or nurse. The duty of confidentiality owed to young people (including those less than 16 years old) is the same as that owed to any other person. A young person under 16 years old can attend appointments without parent/carer involvement. During this appointment the doctor or nurse will make a judgement as to whether the young person has enough maturity and understanding of the situation to make up their own mind. This is called being ‘Gillick competent’. There is no set age for being ‘Fraser competent’ – it depends on each individual young person. The doctor or nurse will decide if a young person is ‘Fraser competent’ by having a chat to them about how they are feeling and what they want.
We will actively encourage young people to discuss any health worries with a parent or carer, and often young people are happy for information to be shared in this way. However, if a young person is judged to be Fraser competent and wishes for this information to remain confidential, we will respect their wishes, unless there are safeguarding concerns.
Consent to treatment
If you give your consent to something, it means you give your permission and you agree. Young people aged 16 years or over have the right to make their own decisions about their health.
There are instances where young people under 16 years old can give their own consent for medical treatment without parent or carer involvement. The doctor or nurse will make a judgement as to whether the young person has enough maturity and understanding of the situation to make up their own mind. This is called being ‘Fraser competent’- See above paragraph.
We hope that by working in this way, young people will be encouraged to seek medical care and advice, and to give the full facts needed in order to provide good care.
Privacy and confidentiality of your medical records
Your medical record is a life-long history of your consultations, illnesses, investigations, prescriptions and other treatments. The doctor-patient relationship sits at the heart of good general practice and is based on mutual trust and confidence. The story of that relationship over the years is your medical record.
Your GP is responsible for the accuracy and safe-keeping of your medical records. You can help us to keep it accurate by informing us of any change in your name, address, marital status and by ensuring that we have full details of your important medical history.
If you move to another area or change GP, we will send your medical records to the local Health Authority to be passed on to your new practice. However, we will keep a copy of all entries into your records whilst you were registered with us.
Who else sees my records?
There is a balance between your privacy and safety, and we will normally share some information about you with others involved in your health care, unless you ask us not to. This could include doctors, nurses, therapists and technicians involved in the treatment or investigation of your medical problems.
This Practice is involved in the teaching of junior doctors/medical students and GP registrars. If you see a trainee during a consultation, they may be given supervised access to your medical record.
Our practice nurses, district nurses, midwives and health visitors all have access to the medical records of their patients. It is our policy to try to have a single medical and nursing record for each patient. We firmly believe that this offers the best opportunity for delivering the highest quality of care from a modern primary care team.
Our practice administration staff have limited access to medical records. They need to notify the health authority of registration and claim details and perform various filing tasks on the medical records.
All our doctors, nurses and staff have a legal, ethical and contractual duty to protect your privacy and confidentiality.
Consent to disclose confidential medical information.
Occasionally, patients may want to nominate a family member or other person to have access to, or share their private medical information. In order to ensure accuracy and safe-keeping of your medical records, we will require you to complete a Consent to Disclose Confidential Medical Information Form. These forms are available from our reception staff,
Where else do we share patient information?
We are required by law to notify the Government of certain infectious diseases (e.g. meningitis, measles but not HIV or AIDS) for public health reasons.
The law courts can also insist that GPs disclose medical records to them. Doctors cannot refuse to cooperate with the court without risking serious punishment. We are often asked for medical reports from solicitors. These will always be accompanied by the patient’s signed consent for us to disclose information. We will not normally release details about other people that are contained in your records (e.g. wife, children, parents etc) unless we also have their consent.
Limited information is shared with health authorities to help them organise national programmes for public health such as childhood immunisations, cervical smear tests and breast screening.
GPs must keep the health authorities up to date with all registration changes, additions and deletions. We also notify the health authority of some procedures that we carry out on patients (contraceptive and maternity services, minor operations, night visits, booster vaccinations) and certain other procedures; where we are paid for performing these procedures.
Social Services, the Benefits Agency and others may require medical reports on you from time to time. These will often be accompanied by your signed consent to disclose information. Failure to cooperate with these agencies can lead to patients’ loss of benefit or other support. However, if we have not received your signed consent we will not normally disclose information about you.
Life Assurance companies frequently ask for medical reports on prospective clients from the GP. These are always accompanied by your signed consent form. GPs must disclose all relevant medical conditions unless you ask us not to do so. In that case, we would have to inform the insurance company that you have instructed us not to make a full disclosure to them. You have the right, should you request it, to see reports to insurance companies or employers before they are sent.
How can I find out what’s in my medical records?
We are required by law to allow you access to your medical records. If you wish to see your records, please contact your practice for further advice. All requests to view medical records should be made in writing to the surgery. We are allowed by law to charge a small fee to cover our administration and costs.
We have a duty to keep your medical records accurate and up to date. Please feel free to correct any errors of fact which may have crept into your medical records over the years.
What we will not do
To protect your privacy and confidentiality, we will not normally disclose any medical information over the telephone or fax unless we are sure that we are talking to you. This means that we will not disclose information to your family, friends or colleagues about any medical matters at all, unless we know that we have your consent to do so.
Our staff will not disclose any details at all about patients over the telephone. Please do not ask them to – they are instructed to protect your privacy above all else!
Safeguarding children and young people
The GP practice staff will make sure that our practice is a safe place for patients, visitors and guests who are under the age of 18. To do this it will make sure:
- All staff know the safeguarding policy.
- There are appropriate procedures in place for dealing with allegations or disclosures of child abuse. · Training is regularly given to all staff
- Checks are made of all staff who will have regular contact with patients under the age of 18.
What is safeguarding?
Everyone has the right to grow up in a safe and caring environment, which includes the right to be protected from all types of abuse. The practice staff have day to day responsibility for safeguarding and will make sure you know they will put your needs first. Our staff will aim to:
- Reassure you
- Listen to you
- Make sure you are safe
- Explain the confidentiality policy
- Explain what will happen next
Employing Staff
The practice will ensure that when employing staff who may work closely with children and young people that these staff will have had full police and identity checks.
If any member of staff was found to have breached confidentiality they would face disciplinary action and may lose their job. All practices have a disciplinary procedure that would be followed. All staff are aware of this and respect the need for you to trust them at all times.
If you feel you have not been treated in a confidential way please talk to the doctor or managing partner who will listen to you and investigate your concerns.
What happens if a member of staff has a safeguarding concern?
Where any professional worker (doctor or nurse) within the practice encounters a situation which causes them to be concerned that any child/young person may be at risk of significant harm, she/he must discuss this with a Clinical Partner. We have a designated lead clinical partner who has received appropriate training in this field.
Where there is an immediate risk of significant harm to the child/young person, the worker will ensure the immediate safety of the child/young person. All cases will be centred around the need and safety of the young person. Confidentiality will be kept within the Practice and the safeguarding network.
At this point we will talk with other professionals, dictated by the context of the young person’s presenting needs, to share information and to help make a decision as to further action. The options include:
- No further action
- Consultation with/referral of concern to the Social Services department Area Team covering where the child/young person at risk of significant harm lives.
- Further assessment, which may subsequently lead to a referral to Social Services or a decision to take no further action.
- Consultation with other professionals outside the practice.
Professionals involved should always make a brief, note about presenting concerns and decisions made. While professional work colleagues will wish to reach agreement on the appropriate course of action to be taken, it is recognised that any professional within the practice may choose to refer the concern to Social Services but this will only occur after full consultation with professional colleagues.
Where there is a risk of immediate harm to a child, the Authority responsible for safeguarding the child’s welfare is that where the child is found at the time of the alleged abuse coming to report. If you would like someone from the practice to talk through this policy with you, please come and talk to a member of staff. We will listen and we will do everything we can to make sure you are safe.