Confidentiality & Medical Records
The practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:
- To provide further medical treatment for you e.g. from district nurses and hospital services.
- To help you get other services e.g. from the social work department. This requires your consent.
- When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.
If you do not wish anonymous information about you to be used in such a way, please let us know.
Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.
Freedom of Information
Information about the General Practioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.
Access to Records
In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so.
Accessing your GP-held records via the NHS app or NHS website
As your GP practice, we have been asked to provide you with, no later than 31 October 2023, access to your full medical record going forward via the NHS app (and NHS website) if you have a suitable NHS login
Your GP medical record contains consultation notes based on conversations between you, your GP and their team: medicines prescribed to you; all test results including hospital investigations; allergies; vaccines; and your medical conditions along with documents that may have been sent from local hospitals, clinics or other agencies, eg the police. There is likely to be sensitive and personal information within your medical record.
We are supportive of providing you with access to your record, but we wish to do this safely and make you aware that this is happening so that you can opt out, if you so wish. You may wish to speak with us first to understand what it is that you will see, and the risks which may be involved in having such confidential data either on your smartphone with the NHS app installed or online if other people might have access to that information through your devices. If you are in a difficult or pressured relationship for example, you may prefer your records to remain accessible only to those treating you, with them not appearing on your smartphone or online. Government has been clear that if a patient does not wish to have access, then we do not have to provide it. This is one reason why we have asked if you wish to opt out, or have it switched off for the time being.
For those who would like access, we are happy to explain the different levels you might like. Everyone can have access to their medication history and allergies, for example, and will be able to order their repeat prescriptions. It’s also possible to request access to what we call your ‘coded record’ where you can see a list of medical problems and results. You can also request access to the ‘full’ record where you will be able to see everything, including the notes which have been written by doctors, nurses and others involved in your care, at the GP surgery, and elsewhere.
It’s important to remember that these documents may, at times, contain information that could be upsetting, especially if they contain news of a serious condition. It can also be a cause for worry seeing results online when it isn’t clear what the results might mean, and no one is available to ask, as can be the case during the evening or at weekends, for example.
Sometimes people with a mental health condition might prefer not to see documents that remind them of difficult times in their life. Letters from mental health teams sometimes go into detail about past events, and great care would be needed in deciding whether you would want to see these letters. It is possible for individual items to be hidden at your request and your GP would be happy to talk about any concerns you may have.
Great care is also needed in case private details might cause harm at home, should people in a difficult or pressured relationship be forced to show their medical record to an abusive partner. Anyone in such a position should make this clear to us at the practice, so we can take steps to keep you safe. This might mean removing access through the NHS app for the time being, or through a careful process where we hide sensitive things. We would talk this through with you.
Requesting access – what do I need to do?
The easiest way to get access is to create an NHS login through the NHS app. Although you can also access your GP records via the internet on a computer, the first bit is easiest if done through a smartphone. If you don’t have one, you may have a family member or friend you trust who can help you. You can also ask your practice receptionist, but you’ll need some proof of who you are, eg a passport, driving licence or household bill.
If you use the NHS app, you’ll have to set up an account using a unique e-mail address and then ‘authenticate’ yourself to the NHS system to prove you are who you say you are. This will involve confirming your name, date of birth and contact details. The NHS login has several levels of authentication and to gain access to your records you’ll need the highest level of authentication. This generally involves you recording a short video of yourself to prove you are a real person as well as uploading a copy of a suitable identification document. Your GP practice can bypass this step if you are struggling, but we’d ask you to try to sign up to the NHS app yourself.
Once you have suitably authenticated yourself to the NHS app and created your NHS login you can approach your practice and ask for access, being mindful of the risks associated with access and the importance of not sharing passwords or having them stored in your smartphone if you think other people might want to see them without your permission. If you have any concerns, you should explain these to your GP practice team who can guide you.
Your GP practice will have a form they will ask you to complete, with your NHS login (this will be the email address you used to sign up) and then you will have a chat about access and your agreement and understanding will be requested. Once you are happy to get online access, your request will be passed to the clinical team to review. It may be that the practice wishes to contact you to discuss your request if there are any concerns raised so that access can be given safely. We’re not sure how many people will ask for access all at once so there may be a wait, but we will do our best to get you online access as soon as we can.
The form to request access can be downloaded HERE
It is your right to request that a chaperone be present during any physical examination undertaken at the surgery.
If you would like the Practice to provide the Chaperone, please could you request this when booking the appointment. We are unable to guarantee a Chaperone is available without notice due to existing staffing commitments.
Consent to Treatment
Consent to treatment is the principle that a person must give their permission before they receive any type of medical treatment.
Consent is required from a patient regardless of the treatment, from blood test to organ donation.
The principle of consent is an important part of medical ethics and the international human rights law.
For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision. These terms are explained below.
Voluntary: the decision to consent or not consent to treatment must be made alone, and must not be due to pressure by medical staff, friends or family.
Informed: the person must be given full information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead. Healthcare professionals should not withhold information just because it may upset or unnerve the person (see below).
Capacity: the person must be capable of giving consent, which means they understand the information given to them and they can use it to make an informed decision. Read about assessing the capacity to consent.
If the person has enough capacity and makes a voluntary and informed decision to refuse a particular treatment, their decision must be respected. This is still true even if their decision would result in their death, or the death of their unborn child.
How to give consent
Consent should be given to the healthcare professional directly responsible for the person's current treatment, such as the nurse arranging a blood test, the GP prescribing new medication or the surgeon planning an operation.
It can be given:
non-verbally, for example, raising a hand to indicate they are happy for a nurse to take a blood sample
in writing, by signing a consent form
If someone is going to have major medical intervention, such as an operation, their consent should be obtained well in advance so they have plenty of time to study any information about the procedure and ask questions.
To consent to a treatment or procedure, the person needs to be fully informed about the treatment and understand why it is considered necessary.
Healthcare professionals should not withhold information just because it may upset or unnerve the person. Even if the person specifically requests not to be told about the extent or likely outcome of their condition, the healthcare professional has a moral and legal responsibility to provide them with at least:
a basic overview of their condition
the likely outcome of their condition
their treatment options
Involving the Court of Protection
There are some circumstances where a decision should always be referred to the Court of Protection if the person cannot give their consent. Situations that should always be referred to the courts include:
sterilisation for contraceptive purposes
donation of regenerative tissue, such as bone marrow
withdrawal of nutrition and hydration from a person who is in a persistent vegetative state
where there is serious concern about the person's capacity or best interests
When consent is not necessary
There are a few exceptions when treatment can go ahead without consent.
One main exception is if a person does not have the mental capacity (the ability to understand and use information) to make a decision about their treatment. In this case, the healthcare professionals can go ahead and give treatment if they believe it is in the person’s best interests. Read more about when consent is not needed.
More information on Consent, can be viewed on the NHS Choices website: www.nhs.uk
End of Life Care Patient Charter
A charter for the care of people who are nearing the end of their life
"You matter because you are you, you matter to the last moment of your life and we will do all we can,not only to let you die peacefully, but to help you live until you die." Dame Cicely Saunders
We want to offer people who are nearing the end of their life the highest quality of care and support. We wish to help you live as well as you can, for as long as you can. Therefore, if and when you want us to, we will:
Listen to your wishes about the remainder of your life, including your final days and hours, answer as best we can any questions that you have and provide you with the information that you feel you need.
Help you think ahead so as to identify the choices that you may face, assist you to record your decisions and do our best to ensure that your wishes are fulfilled, wherever possible, by all those who offer you care and support.
Talk with you and the people who are important to you about your future needs. We will do this as often as you feel the need, so that you can all understand and prepare for everything that is likely to happen.
Endeavour to ensure clear written communication of your needs and wishes to those who offer you care and support both within and outside of our surgery hours.
Do our utmost to ensure that your remaining days and nights are as comfortable as possible, and that you receive all the particular specialist care and emotional and spiritual support that you need.
Do all we can to help you preserve your independence, dignity and sense of personal control throughout the course of your illness.
Support the people who are important to you, both as you approach the end of your life and during their bereavement.
We also invite your ideas and suggestions as to how we can improve the care and support that we deliver to you, the people who are important to you and others in similar situations.
For more information from your Practice Team please contact the Practice Manager on: 01323 482301.
Developed by RCGP English End of Life Working Group, Patient Partnership Group and Royal College of Nursing (2011)
Leading the Way: High-Quality End of Life Care Through General Practice
Complaints can be made by patients, former patients, or someone who is affected, or likely to be affected, by the action, omission or decision of individuals working at the practice - or by a representative of a patient who is incapable of making the complaint themsleves. This is usually a relative or other adult who has an interest in his/her welfare.
Complaints can be made up to 12 months after the incident that gave rise to the complaint, or from when the complainant was made aware of it. Beyond this timescale, it is at the discretion of the practice as to whether to investigate the matter.
Responsible Person: The Responsible person is a Partner of the Practice and responsible for the supervision of the complaints procedure and for making sure that action is taken in light of the outcome of any investigation. This is Dr R Brown.
Complaints Manager: The Complaints Manager is responsible for the handling and investigation of complaints. This is Mrs Anita Taylor, the Practice Manager.
Please email us on: firstname.lastname@example.org
Once a complaint has been investigated, the outcome will be communicated with the complainant. Further information about the complaints procedure including time scales and escalation pathways, can be obtained from our Complaints Procedure leaflet. We also have printed copies available on the front reception desks.