Policies and Procedures

Online Access to your Medical Records

The best and quickest way to see your medical records is online, from where you can print out whatever you need.

To gain online access you will need a PIN code available from reception, which will allow you to see much but not all of your records. You can usually obtain the PIN code within minutes. Beware that if you give your PIN codes and passwords to other people, they will be able to see your confidential medical records.

To have access to ALL of your medical records, you will need to complete a 2nd form. This request can take up to 5 days to process, as we need to be sure that information about other people is not in you records, as such information can legally be withheld.

The NHS is strongly encouraging patients to go online to view their records, book and cancel appointments, and to request repeat medication.

If you need help to set up online access and have no family or friends who can assist, the NHS advises to you to seek help from your local public library.

Obtaining copies of your medical records

If you would like the practice to provide copies of any part of your record instead of going online, please complete the form below.

How long does it take?

By law, under the General Data Protection Regulations of 2018, you’re entitled to receive a response no later than one calendar month after your application is received.

Can you apply to see someone else’s medical records?

Health records are confidential so you can only access someone else’s records if you’re authorised to do so.

To access someone else’s health records, you must:

• be acting on their behalf with their consent, or · have legal authority to make decisions on their behalf (power of attorney), or
• have another legal basis for access

Summary

Regardless of the patient’s role, the guidelines from medical regulatory bodies are clear: it is always the doctor’s responsibility to manage and maintain professional boundaries – utilising chaperones effectively is a way of managing relations with patients, where the ultimate responsibility for ensuring that relations remain on professional footing rests with you.

Background

In 2004 the Committee of Inquiry looked at the role and use of chaperones, following its report into the conduct of Dr Clifford Ayling (see useful links). It made the following recommendations:

• Each trust should have its own chaperone policy and this should be made available to patients.
• An identified managerial lead (with appropriate training).
• Family members or friends should not undertake the formal chaperoning role.
• The presence of a chaperone must be the clear expressed choice of the patient; patients also have the right to decline a chaperone.
• Chaperones should receive training.

Why use chaperones?

• Their presence adds a layer of protection for a doctor; it is very rare for a doctor to receive an allegation of assault if they have a chaperone present.
• To acknowledge a patient’s vulnerability.
• Provides emotional comfort and reassurance.
• Assists in the examination.
• Assists with undressing patients.
• Enables them to act as an interpreter.

What is an intimate examination?

Obvious examples include examinations of the breasts, genitalia and the rectum, but it also extends to any examination where it is necessary to touch or be close to the patient; for example, conducting eye examinations in dimmed lighting, taking the blood pressure cuff, palpitating the apex beat.

The chaperone policy

Here is a useful checklist for the management of a consultation:

• Establish there is a need for an intimate examination and discuss this with the patient.
• Explain why an examination is necessary and give the opportunity to ask questions; obtain and record the patient’s consent.
• Offer a chaperone to all patients for intimate examinations (or examinations that may be construed as such). If the patient does not want a chaperone, record this in the notes.
• If the patient declines a chaperone and as a doctor you would prefer to have one, explain to the patient that you would prefer to have a chaperone present and, with the patient’s agreement, arrange for a chaperone.
• Be aware and respect cultural differences. Religious beliefs may also have a bearing on the patient’s decision over whether to have a chaperone present.
• Give the patient privacy to undress and dress. Use paper drapes where possible to maintain dignity.
• Explain what you are doing at each stage of the examination, the outcome when it is complete and what you propose to do next. Keep the discussion relevant and avoid personal comments.
• Record the identity of the chaperone in the patient’s notes.
• Record any other relevant issues or concerns immediately after the consultation.
• In addition, keep the presence of the chaperone to the minimum necessary period. There is no need for them to be present for any subsequent discussion of the patient’s condition or treatment.

(Written information detailing the policy has been provided for patients,  in the form of a letter on the notice board)

Where should the chaperone stand?

Exactly where the chaperone stands is not of major importance, as long as they are able to properly observe the procedure so as to be a reliable witness about what happened.

Key points to remember

• Inform your patients of the practice’s chaperone policy.
• Record the use, offer and declining of a chaperone in the patient’s notes.
• Ensure training for all chaperones.
• GPs do not have to undertake an examination if a chaperone is declined.
• Be sensitive to a patient’s ethnic/religious and cultural background. The patient may have a cultural dislike to being touched by a man or undressing.
• Do not proceed with an examination if you feel the patient has not understood due to a language barrier.

If you have a complaint or concern about the service you have received from the doctors or any of the staff working in this GP surgery, please let us know. This includes Primary Care Network staff working as part of our GP surgery. We operate a complaints procedure as part of an NHS system for dealing with complaints. Our complaints system meets national criteria.

How to complain

We hope that most problems can be sorted out easily and quickly when they arise and with the person concerned. For example, by requesting a face-to-face meeting to discuss your concerns.

If your problem cannot be sorted out this way and you wish to make a complaint, we would like you to let us know as soon as possible. By making your complaint quickly, it is easier for us to establish what happened. If it is not possible to do that, please let us have details of your complaint:

• Within 6 months of the incident that caused the problem; or
• Within 6 months of discovering that you have a problem, provided this is within 12 months of the incident.

Complaints should be addressed to the GP surgery team verbally or in writing to the Practice Manager. Alternatively, you may ask for an appointment with the GP surgery to discuss your concerns. They will explain the complaints procedure to you and make sure your concerns are dealt with promptly. Please be as specific as possible about your complaint.

What we will do

We will acknowledge your complaint within three working days. We will aim to have investigated your complaint within ten working days of the date you raised it with us. We will then offer you an explanation or a meeting with the people involved, if you would like this. When we investigate your complaint, we will aim to:

• Find out what happened and what went wrong.
• Make it possible for you to discuss what happened with those concerned, if you would like this.
• Make sure you receive an apology, where this is appropriate.
• Identify what we can do to make sure the problem does not happen again.

Complaining on behalf of someone else

We take medical confidentiality seriously. If you are complaining on behalf of someone else, we must know that you have their permission to do so. A note signed by the person concerned will be needed unless they are incapable (because of illness) of providing this.

Complaining to NHS England

We hope that you will use our Practice Complaints Procedure if you are unhappy. We believe this will give us the best chance of putting right whatever has gone wrong and an opportunity to improve our GP surgery.

However, if you feel you cannot raise the complaint with us directly, please contact NHS England. You can find more information on how to make a complaint at https://www.england.nhs.uk/contact-us/complaint/complaining-to-nhse/.

Unhappy with the outcome of your complaint?

If you are not happy with the way your complaint has been dealt with by the GP surgery and NHS England and would like to take the matter further, you can contact the Parliamentary and Health Service Ombudsman (PHSO). The PHSO makes final decisions on unresolved complaints about the NHS in England. It is an independent service which is free for everyone to use.

To take your complaint to the Ombudsman, visit the Parliamentary and Health Service Ombudsman website or call 0345 015 4033

Need help making a complaint?

If you want help making a complaint, Healthwatch Hounslow can help you find independent NHS complaints advocacy services in your area.

Alternatively, POhWER is a charity that helps people to be involved in decisions being made about their care. Call POhWER’s support centre on 0300 456 2370 for advice.

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:

1. Reassure you
2. Listen to you
3. Make sure you are safe
4. Explain the confidentiality policy
5. 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.

The practice has access providing lifts to the first floor, additionally suitable washrooms

1. Introduction
   This information security policy shall apply to information, systems, networks, applications, locations and staff of Spring Grove Medical Practice. It is based on the expectations set out within the Information Security Management: Code of Practice for NHS organisations (see http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/policy/code-of-practice).

   The purpose of this policy is to enable and maintain effective security and confidentiality of information processed or stored by the practice. This shall be achieved by:
   – Ensuring that all members of the practice staff are aware of and shall comply with relevant legislation, including GDPR -2018 (General Data Protection Regulations), the Data Protection Act (1998) and the Data Protection (Processing of Sensitive Personal Data) Order 2000.

   – Describing the principles of information security management and describing how they shall be implemented within the practice.

   – Introducing an approach to information security that is consistent with other NHS organisations.

   – Assisting staff to identify and implement information security as an integral part of their day to day role within the practice.

   – Safeguarding information relating to staff and patients under the control of the practice.

2. Objectives
   Key objectives of this Practice Information Security Policy are to preserve:
   – Confidentiality – Access to information shall be restricted to those GPs and staff of the practice and relevant others with agreed authority to view it.

   – Integrity – Records are to be complete and accurate with all filing and management systems operating correctly.

   – Availability – Information shall be readily available and delivered to the authorised GP or medical professional, when it is needed.

3. Responsibilities for Information Security
   – Responsibility for information security shall rest with the Dr Luthra the senior partner. However, on a day-to-day basis Dr Luthra and Meenakshi Luthra practice manager shall be responsible for organising, implementing and managing this policy and its related good working practices

   – Both shall be responsible for ensuring that both permanent and temporary staff including any contractors and locums are aware of:-

   – The information security policies applicable to their work areas

   – Their personal responsibilities for information security

   – Who to ask or approach for further advice on information security matters.

   – All staff shall abide by security procedures of the practice. This shall include the maintenance of Practice records whilst ensuring that their confidentiality and integrity are not breached this applies to patient, staff and practice information. Failure to do so may result in disciplinary action.

   – This Information Security Policy document shall be owned, maintained, reviewed and updated by Dr Luthra This review shall take place annually.

   – Staff shall be responsible for both the security of their immediate working environments and for security of information systems they use [eg workstations, laptops, PDAs, cardex etc].

   – Any contracts with third party organisations that allow access to the information systems of the practice, shall be in place before access is allowed. These contracts shall ensure that the staff or sub-contractors of those external organisations shall comply with all the appropriate security policies / guidance required by the practice.

   The Practice shall undertake to ensure:
   1. Contracts of Employment – address information security requirements at the recruitment stage and that all contracts of employment shall contain a confidentiality clause. The information security requirements shall be included within job descriptions.

   2. Access Controls – to areas containing information systems are restricted and controlled to ensure that only GPs and those authorised can access information of the Practice.

   3. Equipment Security – is effective in order to minimise losses, or damage to the Practice. All information assets and equipment shall, where possible be physically protected from security threats and environmental hazards. (Locked cabinets (fire proof if possible), clear desk policy and the limitation of risks in the surrounding work area etc).

   4. Information Risk Assessment – a regular assessment of the working environment, shall be conducted to identify potential risks to the security of Practice information. Where risks are identified, these should be noted and where possible mitigating action taken.

   5. Security Incidents and weaknesses – are to be recorded and reported to Dr Luthra so that they can be investigated to establish their cause, impact and the effect on the Practice and its patients. (NB. remedial changes arising may need to be included within future staff working procedures, updates to policies and contracts of employment).

   6. Protection from Malicious Software – should be provided through the use of commercial strength anti-virus/anti-malware software. Where there is an internet connection an appropriate firewall shall be installed and managed. No new software shall be downloaded or installed on computer systems of the Practice without the explicit permission of Dr Luthra. Breach of this requirement may be subject to disciplinary action.

   7. Secure Communications – should be in place to ensure that all correspondence, faxes, email, telephone messages and transfer of patient records are conducted in a secure and confidential manner. The communication of NHS Confidential or NHS restricted information by email must be appropriately protected, using cryptographic controls (AES 256 bit or equivalent). NB: When using NHSmail this technical security protection is automatic.

   8. Business Continuity and Disaster Recovery Plans – are in place so that in the event of a disruption to the information services of the Practice, it is possible to activate relevant business contingency plans until affected services are restored.

   9. Individual Login and access to information

All access to clinical information requires individual login, and other sensitive documents are password protected.

You can tell your GP practice if you do not want your confidential patient information held in your GP medical record to be used for purposes other than your individual care. This is commonly called a type 1 opt-out. This opt-out request can only be recorded by your GP practice.

To register a Type 1 opt-out at Spring Grove Medical Practice, please download the form seen below, fill it in and return it to the practice.

• Form link  https://www.springgrovemedicalpractice.co.uk/files/2021/08/National-Type-1-Opt-out-Form.pdf

Read/Download out Practice Charter

How we use your medical records

Important information for patients

• This practice handles medical records in-line with laws on data protection and confidentiality.
• We share medical records with those who are involved in providing you with care and treatment.
• In some circumstances we will also share medical records for medical research, for example to find out more about why people get ill.
• We share information when the law requires us to do so, for example, to prevent infectious diseases from spreading or to check the care being provided to you is safe.
• You have the right to be given a copy of your medical record.
• You have the right to object to your medical records being shared with those who provide you with care.
• You have the right to object to your information being used for medical research and to plan health services.
• You have the right to have any mistakes corrected and to complain to the Information Commissioner’s Office. Please see the practice Privacy Policy on Spring Grove Medical Practice website www.springgrovemedicalpractice.co.uk or speak to a member of staff for a copy of the privacy policy.

Read/Download our Privacy Policy

Your Summary Care Record contains important information about any medicines you are taking, any allergies you suffer from and any bad reactions to medicines that you have previously experienced.

Allowing authorised healthcare staff to have access to this information will improve decision making by doctors and other healthcare professionals and has prevented mistakes being made when patients are being cared for in an emergency or when their GP practice is closed.

Your Summary Care Record also includes your name, address, date of birth and your unique NHS Number to help identify you correctly.

You may want to add other details about your care to your Summary Care Record. This will only happen if both you and your GP agree to do this. You should discuss your wishes with your GP practice.

Healthcare staff will have access to this information, so that they can provide safer care, whenever or wherever you need it, anywhere in England.

National Opt-out (Type 1)

You can tell your GP practice if you do not want your confidential patient information held in your GP medical record to be used for purposes other than your individual care. This is commonly called a type 1 opt-out. This opt-out request can only be recorded by your GP practice.

To register a Type 1 opt-out at Spring Grove Medical Practice, please download the form seen below, fill it in and return it to the practice.

NHS Zero Tolerance Policy

The practice fully supports the NHS Zero Tolerance Policy. The aim of this policy is to tackle the increasing problem of violence against staff working in the NHS and ensures that doctors and their staff have a right to care for others without fear of being attacked or abused.

We understand that ill patients do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint. At all times we try to be polite and courteous to our patients, and request that you treat our staff in a similar way.

Aggressive behaviour of a physical or verbal nature towards our staff or other patients will not be tolerated, and may result in you being removed from the Practice list, and in extreme cases the police may be contacted.

Removal from the Practice List

A good patient-doctor relationship, based on mutual respect and trust, is the cornerstone of good patient care. The removal of patients from our list is an exceptional and rare event and is a last resort in an impaired patient-practice relationship. When trust has irretrievably broken down, it is in the patient’s interest, just as much as that of the practice, that they should find a new practice. An exception to this is on immediate removal on the grounds of violence e.g. when the police are involved.

Removing other members of the household

In rare cases, however, because of the possible need to visit patients at home it may be necessary to terminate responsibility for other members of the family or the entire household. The prospect of visiting patients where a relative who is no longer a patient of the practice by virtue of their unacceptable behaviour resides, or being regularly confronted by the removed patient, may make it too difficult for the practice to continue to look after the whole family. This is particularly likely where the patient has been removed because of violence or threatening behaviour and keeping the other family members could put doctors or their staff at risk.