Why we collect your data

Stansted Surgery collects personal data of its registered patients in order to provide the best possible health care to those patients.

• We collect data about your NHS number, name, address and date of birth details so that we can verify your identity when we provide you with health care.
• We collect data about your contact details so that we can contact you regarding your direct health care.
• We collect medical information about you in order to inform decisions about your health care.
• We collect medical information so we can contact you for the purpose of taking part in clinical research studies

What data we collect about you

When you register at Stansted Surgery, you will sign an NHS registration form. This gives your consent to your previous GP surgery to send any medical records held about you to us. 

We add to these medical records every time you interact with the surgery regarding your direct health care, including booking appointments, issuing medication, attending the surgery for a consultation, or making a referral on your behalf.

Your medical records held at Stansted Surgery consist of:

• Your medication, past and present
• A history of medical consultations and the problems addressed in those consultations
• A history of medical diagnoses
• A history of diagnostics and test results
• A history of immunisations and allergies
• A history of referrals
• Clinical letters and discharges sent to your GP by hospitals and other health care institutions
• A history of appointments

We only collect information relevant to your health care on your medical record.   However, this does sometimes include details of social support and care packages where these are relevant to your health care.     

How we use your data

Clinicians

We respect the confidentiality of our patients’ data, and understand that confidential information is provided by patients to an individual clinician within the confines of a consultation. 

Our clinicians work as a team to provide the best possible care to our patients.  Patients may see different doctors, nurses and healthcare assistants in Stansted Surgery over time, and those doctors and nurses will access records of previous consultations in order to provide continuity in your care.   

Clinicians also consult each other about individual patients on occasion, in order to check their thinking and ensure the patient is given the best possible advice.   The clinician will normally tell you that they are going to do this. When you need to be referred to Secondary Care, a summary of your medical records may be shared with the hospital, to enable them to provide you with the best possible care.

Allied Health Professionals

We have a number of allied health professionals who, while not employed by Stansted Surgery, work closely as part of the clinical team at Stansted to provide direct patient care.  This includes District Nurses; Health visitors; School Nurses; Midwifes; Cambridge University Medical Students, Visiting Paramedics, and Dietician (for diabetic clinics). These individuals sign a confidentiality agreement with Stansted Surgery, and may access aspects of your medical record where relevant to providing you with direct patient care. 

Non-Clinical Staff

Our administrative staff accesses your medical records in order to support the doctors and nurses providing your care.  For example, the medical secretaries will access your records to process a referral made by the doctor on your behalf.  Receptionists will access your records to provide you with test results once the doctor has reviewed those test results.

Using your data for purposes other than direct patient care

We use your contact details to send text messages like appointment reminders, and to e-mail newsletters and similar bulk e-mail communications.  New patients are asked to opt in or out of this.  Once opted in, you can opt out at any time.

How we protect your data

Medical records access is controlled by NHS “Smartcards” individual to each staff member or allied health professional. Smartcards are issued following identity checks conducted by the local NHS Smartcard Team. All staff have annual training in information governance, and all staff have confidentiality clauses written into their employment contracts.  In addition, each time someone accesses your medical record, be it a doctor or a member of staff, an audit trail is created.  Any inappropriate access by staff, or any misuse of confidential information, would potentially constitute gross misconduct.   Your medical records are stored electronically on our clinical system, EMIS.  EMIS is a national supplier of clinical systems for GPs, and is accredited by the NHS.  We also have paper copies of medical records that pre-date automated transfer of medical records between surgeries.  These are stored in an area not accessible by patients, and locked overnight.

Sharing your data for direct patient care

We share your data with other health care providers for the purposes of direct patient care.  Except in exceptional circumstances (see below), this will always be with your consent.  For example, you and your GP may agree that it is appropriate to refer you to a hospital consultant.  Your consent to the referral implies that you are consenting to your GP sharing relevant parts of your medical record with the consultant and his team.  We share your data with Stellar Health Care who are contracted by West Essex CCG to provide extended hours GP and nursing appointments in evenings and weekends at Saffron Walden and Great Dunmow. The clinician who sees you at these appointments should always ask for your consent prior to accessing your data on EMIS.  Unless you have opted out, we share your “Summary Care Record” on the NHS Spine, where it can be accessed by hospitals and other NHS organisations, for example, A&E.  The clinician who sees you should always ask for your consent prior to accessing your data.  For diabetic patients, we share your data with Health Intelligence who are contracted to run the Diabetic Retinal Screening for North and West Essex.  New diabetic patients will be asked to opt into this.  You can opt out at any time.  

Sharing data for direct patient care without your consent.

We will share data about you for the purpose of direct patient care but without your consent where:

1. We are required to do so by law
2. There is an immediate and significant risk to your, or somebody else’s safety. 
3. A doctor takes the view that it is in your best interests to do so, and that you do not have the mental capacity to take the decision yourself.

 Sharing Data for Research and to comply with legal obligation

Stansted Surgery is active in medical research to support the effectiveness and safety of medicines and medical devices.  Participation in most research projects is with your explicit consent – which must be freely given, specific, informed and unambiguous.  However, there are also some research projects where we contribute anonymised data.  You can opt in or out of these. From time to time, this practice contributes to national clinical audits and will send the data which are required by NHS Digital when the law allows. This may include demographic data, such as date of birth, and information about your health which is recorded in coded form, for example, the clinical code for diabetes or high blood pressure.  Currently, we participate in the National Diabetes audit.  New patients are asked to opt in or out of this.  Once opted in, you can opt out at any time.  In order to comply with its legal obligations this practice may send data to NHS Digital when directed by the Secretary of State for Health under the Health and Social Care Act 2012.

Your rights

You have a right to access your medical record.  We can provide you with secure on-line access, or we can e-mail electronic copies, with your consent and understanding that you are responsible for the security of your e-mail account. Any information concerning third parties (e.g. other family members) will be removed from your record before we provide access. 

You have a right to have inaccurate data corrected.  We will investigate any reported inaccuracies, and where appropriate make a correction, with an audit trail of what was corrected and why.

Your medical records will be retained until death, at which point they are sent from the surgery to a central NHS body, from where they can be retrieved by individuals with a legal right to do so.

You have the right to lodge a complaint with the Information Commissioner’s Office (ICO).

The practice welcomes constructive feedback on your experience with us and is positive about using this to improve what we do. We record all complaints and compliments and this gets fed back to our staff.

If you wish to see how to complain please click here

To complete a complaint or compliment form please click here 

Please e-mail this to the surgery at [email protected]

The people caring for you need access to your health and care record in order to make the best decisions about your diagnosis and treatment. For this to happen more quickly and to improve the care you receive, a new process has been put in place. With your permission, My Care Record will provide health and care professionals directly involved in your care, access to the most up-to-date information about you. To find out more please go to www.mycarerecord.org.uk

All patients registered at the practice have a named accountable GP. You can find out who this is by contacting the practice or asking during your next consultation.   Whilst this GP is accountable for your care it does not mean that you have to see that GP and it is highly likely that you may be seen by another available clinician . This is to ensure that patients can be seen in a timely manner as the need arises. You may of course ask for the next available appointment for the GP or PCP of your choice.

Our approach to your healthcare

We promise to treat everyone as an individual, with no discrimination. Our patients will be treated as people, not just a medical condition. This means we plan care which emphasises the patient’s individual needs with dignity and strict confidentiality.

The care given will be research-based and delivered to the highest standard. Advice, support and information will be available in order to help our patients make the right choices. We will set standards of care and review them periodically, in the form of audits, and we will act upon these appropriately.

Patient’s rights and responsibilities

As a patient you have the right to:
a) be seen by the doctor of your choice (but please remember that you may have to see any of the doctors if your need is urgent)
b) receive emergency care
c) receive appropriate drugs and medicines
d) be referred for specialist or second opinion if they and GP agrees
e) see your medical records or a copy, subject to certain laws
f) know that by law, everyone working for the NHS must keep the contents of your medical records private.

With these rights come responsibilities for you as the patient. That means being:
a) courteous to staff at all times
b) as prompt as possible for all appointments
c) responsible for cancelling appointments in adequate time

Also please do not smoke in the surgery and do not use mobile phones out of courtesy to other patients and due to the effect on some of our medical equipment.

Policy on violent or abusive patients

We support the NHS ZERO Tolerance policy.

The practice is committed to providing high quality care to our patients. The relationship between the patients and those working in the surgery is important. Therefore, in order to protect both the staff and other patients the following inappropriate behaviour will not be tolerated:

Swearing
Threatening or abusive behaviour
Drunkenness
Verbal/physical abuse

Posts on Social Media

Such behaviour has a marked effect on staff and other patients and where it is observed, we reserve the right to withhold treatment from the offender and to ensure their removal from the premises. This type of behaviour may lead to a patient being removed from the Practice register.

Who has access to patient information

We respect your right to privacy and keep all your health information confidential and secure. It is important that the NHS keeps accurate and up-to-date records about your health and treatment so that those treating you can provide the best possible care. We have a fully computerised medical record system which means information about your healthcare is held on a secure server. You have the right to know what information we hold about you. Please ask the receptionist if you wish to see or obtain a copy of your record.

Stansted Surgery – VULNERABLE ADULT STATEMENT

WHAT IS A VULNERABLE ADULT?

The definition is wide, however this may be regarded as anyone over the age of 18 years who may be unable to protect themselves from abuse, harm or exploitation, which may be by reason of illness, age, mental illness, disability or other types of physical or mental impairment.

Those at risk may live alone, be dependent on others (care homes etc.), elderly, or socially isolated.

FORMS OF ABUSE

• Neglect – ignoring mental or physical needs, care, education, or basic life necessities or rights
• Bullying – family, carers, friends
• Financial – theft or use of money or possessions
• Sexual – assault, rape, non-consensual acts (including acts where unable to give consent), touching, indecent exposure
• Physical – hitting, assault, man-handling, restraint, pain or forcing medication
• Psychological – threats, fear, being controlled, taunts, isolation
• Discrimination – abuse based on perceived differences and vulnerabilities
• Institutional abuse – in hospitals, care homes, support services or individuals within them, including inappropriate behaviours, discrimination, prejudice, and lack of essential safeguards

Abuse may be deliberate or as a result of lack of attention or thought, and may involve combinations of all or any of the above forms. It may be regular or on an occasional or single event basis, however it will result in some degree of suffering to the individual concerned. Abuse may also take place between one vulnerable adult and another, for example between residents of care homes or other institutions.

INDICATIONS

• Bruising
• Burns
• Falls
• Apparent lack of personal care
• Nervousness or withdrawn
• Avoidance of topics of discussion
• Inadequate living conditions or confinement to one room in their own home
• Inappropriate controlling by carers or family members
• Obstacles preventing personal visitors or one-to-one personal discussion
• Sudden changes in personality
• Lack of freedom to move outside the home, or to be on their own
• Refusal by carers to allow the patient into further care or to change environs
• Lack of access to own money
• Lack of mobility aids when needed

Where abuse of a vulnerable adult is suspected the welfare of the patient takes priority. In deciding whether to disclose concerns to a third party or other agency the GP will assess the risk to the patient. Ideally the matter should be discussed with the patient involved first, and attempt made to obtain consent to refer the matter to the appropriate agency. Where this is not possible, or in the case of emergency where serious harm is to be prevented, the patient’s doctor will balance the need to protect the patient with the duty of confidentiality before deciding whether to refer. The patient should usually be informed that the doctor intends to disclose information, and advice and support should be offered. Where time permits, the medical defence organisation will be telephoned before any action is taken.

Due regard will be taken of the patient’s capacity to provide a valid consent. (See also Consent Protocol).

In assessing the risk to the individual, the following factors will be considered:

• Nature of abuse, and severity
• Chance of recurrence, and when
• Frequency
• Vulnerability of the adult (frailty, age, physical condition etc.)
• Those involved – family, carers, strangers, visitors etc.
• Whether other third parties are also at risk (other members of the same household may being abused at the same time)

If any Patient suspects that an adult may be vulnerable and “at risk” please advise one of the Practice Partners, or a member of management – in confidence

20/11/2018

We would like to share your health care record information with other local health care organisations i.e. Princess Alexandra Hospital so that if you need their help they have access to all the relevant up to date information to help them, help you. Click on the following links to find out more

About My Health care Record

My Care record Opt Out Form

Further Information about My Care record can be found at http://www.mycarerecord.org.uk/faqs

About Share My care Record

https://digital.nhs.uk/scr#main-content

Share my care Opt Out Form

If you want to see details of your records you can now do this on line.  As well as booking appointments on line you will be able to see various results and consultations. We will need to verify your identity (photo id required in person) to provide access.  Please come to reception and they will provide the necessary forms and checks.

Freedom of Information – Publication Scheme

The Freedom of Information Act 2000 obliges the practice to produce a Publication Scheme. A Publication Scheme is a guide to the ‘classes’ of information the practice intends to routinely make available. This scheme is available from the practice manager.

Confidentiality

We ask you for personal information so that you can receive appropriate care and treatment. This information is recorded on computer and we are registered under the Data Protection Act. The practice will ensure that patient confidentiality is maintained at all times by all members of the practice team. However, for the effective functioning of a multi-disciplinary team it is sometimes necessary that medical information about you is shared with other healthcare professionals. Please be aware we are unable to discuss patient details even with another family member unless we have written permission (This does not apply to minors other than in special circumstances).

Access to Medical Records

You have a right to access your health records. To do so, please collect a Subject Access Request from Reception, or request a copy of the form by emailing [email protected]